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Based on review of hospital policies and procedures, hospital records and staff interviews, the hospital failed to report unprofessional conduct with WAC 246-16-220, 270 Mandatory reporting.
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Failure to report to the Department when the unprofessional conduct incident occurred potentially placed patients at risk for harm which may include inadequate pain control, exposure to blood borne pathogens and care by impaired healthcare workers.
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References:
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WAC 246-16-220 Mandatory reporting-How and when to report:
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(1) Reports are submitted to the department of health. The department will give the report to the appropriate disciplining authority for review, possible investigation and further action.
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(b) Reports of unprofessional conduct are submitted to the department.
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WAC 246-16-270 Mandatory reporting-Reports by employers of license holders.
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(1) Every license holder, corporation, organization, health care facility, and state and local governmental agency that employs a license holder shall report to the department of health when the employed license holder's services have been terminated or restricted based on a final determination or finding that the license holder: (a) Has committed an act or acts that may constitute unprofessional conduct.
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Findings include:
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1. Review of the Northwest Hospital (NWH) Policy entitled: "Drug Diversion Prevention & Incident Management " (Effective 7/09; Reviewed 4/14) read in part:
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"VI: Drug Diversion Prevention. B. Recommended drug diversion prevention strategies are:

9. Report attempted inappropriate access to medications to pharmacy and your manager."
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" E. External Drug Diversion Reporting Requirements:
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"1. The Pharmacy Director or designee notifies regulatory bodies as required. 2. Unit/Department Manager notifies the Department of Health."
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Under Appendix II: " Behavioral Indicators of Potential Drug Diverters " of the same policy it read " 2. Frequent, unexplained disappearances during the shift."
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2. Review of former surgical technologist's (Staff A) personnel file was done on 3/23/2016 with the hospital attorney (Staff G). The employee began employment on 12/30/2011. The file had a notation in the employee record which stated, "March 8, 2012 let go for touching a syringe in the OR (operating room) which had Propofol (medication used for the induction of anesthesia). Immediately let go and the syringe was taken out of the immediate procedural area. Fired on 3/9/2012."
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3. On 3/23/2016 at 9:30 AM, the Surgical Services Manager (Staff C) was interviewed. The surgical services manager remembered Staff A. He/She stated that the employee was fired for not following facility policies. The employee touched a syringe on the anesthesia cart which surgical technologists were not allowed to do. The employee had been counseled to not stand around the anesthesia carts. The employee had tried to follow patients in to the post anesthesia recovery unit and was told surgical technologists were not allowed near these areas in surgery.
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The Surgical Services Manager went on to say the syringes Staff A touched were taken out of circulation and a drug count done at the time did not reveal any missing medications. The medications were destroyed. The department of health was not called since no medications were missing. No documents were provided regarding the investigation of the incident.
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4. On 3/23/2016 at 1:00 PM the Chief Nursing Officer (Staff B) was interviewed. The nursing officer verified the above findings.
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5. On 3/25/2016 at 1:45 PM, the investigator asked the Chief Nursing Officer (Staff B) for a copy of the incident report filed at the time Staff A was observed touching the syringe in the operating room.
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The hospital provided a document dated 3/8/2012 that read in part "Last night, at 1830 in room 3 while inducing the patient I witnessed [Staff A] (scrub tech) near the anesthesia cart. At that time he handed [the anesthesia provider] a syringe of Propofol, anesthesia blades, and ET tube. He then left the room for a short while and came back to the same area (anes cart). I then noticed him dropping a syringe labeled "dilaudid" on the anesthesia cart. [Staff A] again left the room for awhile and came back scrubbed in for the case."

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7. On 3/30/2016 at 10:15 AM the Pharmacy Manager (Staff D) was interviewed. The pharmacy manager indicated that at the time of the 3/7/2012 incident pharmacy was not directly involved with the investigation. Pharmacy was not notified of any possible drug diversion activities regarding Staff A. The chief quality officer (Staff E).was present during the interview with staff D and agreed with his/her recollection.
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Based on interview and document review, the hospital failed to implement their policy and procedure in order to ensure suspected staff diversion behaviors prompted necessary investigation and communication to assess patient risk.
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Failure to investigate and communicate suspected diversion behaviors places patients at risk for harm which may include inadequate pain control, exposure to blood borne pathogens and care provided by impaired healthcare workers.
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Reference:
Chapter 246-873 Pharmacy - Hospital Standards 246-873-080 (7) Controlled substance accountability. The director of pharmacy shall establish effective procedures and maintain adequate records regarding use and accountability of controlled substances, and such other drugs as appropriate, in compliance with state and federal laws and regulations.
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Findings include:
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1. The Northwest Hospital Medical Center (NWHMC) Policy-Administration "Fitness for Duty" (Revised 8/09; Reviewed 3/16) read in part " III. Procedure 6. If drug or alcohol use is suspected, the employee will be required to submit to a reasonable suspicion drug or alcohol test at no expense to the employee (see Attachment A Drug and or/Alcohol Testing and Signs and Symptoms which may indicate impairment).
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" Attachment A "
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For purposes of this policy, "Reasonable Suspicion means that there are sufficient objective factors read in part, " frequently absent from unit/department during shift."
" Reasonable Suspicion Drug/Alcohol Testing Procedure ":
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Read in part "1. The supervisor should relieve the employee of job duties immediately, contact Human Resources or the Nursing Supervisor if after regular hours, and call the designated lab sites directly, notifying the lab site that the employee is being sent for testing. 2. The employee will be placed on administrative leave until test results are known."
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2. The NWHMC policy Administration "Drug Diversion Prevention & Incident Management " under "Appendix II: Behavioral Indicators of Potential Diverters " read in part " 2. Frequent, unexplained disappearances during shift ." Under E. "External Drug Diversion Reporting Requirements " " 2. Unit/Department Manager notifies the Department of Health."
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3. On 3/25/2016 the hospital provided a document dated 3/8/2012 that read in part "Last night, at 1830 in room 3 while inducing the patient I witnessed [Staff A] (scrub tech) near the anesthesia cart. At that time he handed [the anesthesia provider] a syringe of Propofol, anesthesia blades, and ET tube. He then left the room for a short while and came back to the same area (anes cart). I then noticed him dropping a syringe labeled "dilaudid " on the anesthesia cart. [Staff A] again left the room for awhile and came back scrubbed in for the case. "
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The incident report went on to say the incident primary outcome was: "potential injury/Unsafe condition. Under overall severity it stated "unclear."
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The incident report was closed for review on December 3, 2013. The incident report stated "Further investigation occurred surrounding employee [Staff A]. Employee [Staff A] ultimately released from employment during probationary period". There was no documentation about whether Staff A was pulled immediately from duty and/or participation in the operation, drug tested or whether the content of the syringes on the anesthesia cart were tested. Nor was there any documentation about who was notified about Staff A's behaviors.
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4. On 3/23/2016 at 8:50 AM, Staff D, the Medical Director of Infectious Diseases was interviewed. The medical director stated on 2/6/2016 the hospital was notified by the local health department about the possibility patients may have been exposed to blood borne pathogens during the time Staff A worked at the facility. Staff A had been alleged in another facility to be changing out surgical needles and possibly medications. The hospital was working with the health department to notify and test the patients treated in their facility during the time Staff A worked at the facility.
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5. On 3/23/2016 at 9:30 AM the Surgical Services Manager, (Staff C) was interviewed. Staff C stated that Staff A was fired on 3/9/2012 for not following facility policies.
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He/She went on to say surgical technologists could not handle medications on the anesthesia carts. At the time Staff A was fired, no medications were determined to be missing. The medications on the anesthesia cart where Staff A had been working on 3/7/2012 were taken out of circulation immediately. No supporting documentation was provided regarding the hospital's investigation or what steps were taken to ensure medications had not been tampered with or other precautionary measures to assess patient risk in reponse to the 3/7/2012 incident.
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6. On 3/23/2016 at 1:00 PM, the above findings were verified with Chief Nursing Officer, Staff B.
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7. On 3/30/2016 Staff A's employee file was reviewed. The employee was hired on 12/30/2011 and was terminated on 3/9/2012. The last day the employee worked in the facility was on 3/7/2012. Just prior to Staff A's termination, the human resources manager at the time had documented concerns related to Staff A's behavior. The concerns documented in Staff A's employee file were that he/she was observed taking a sharps container into the bathroom, attempting to follow patients into the recovery room, probing in a sharps container, cleaning up the anesthesia machine which was not part of his/her job, seen in the stretcher room with a sharps container and needing to be paged to return to his/her work station.
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The Chief Quality Officer verified on 3/30/2016 at 5:20 PM, the notes written in Staff A's file were written by the human resources manager at the time Staff A was terminated from employment.
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8. On 3/30/2016 at 2:10 PM the Surgical Services Manager (Staff C) was interviewed again. He/She stated at the time of the incident on 3/7/2012 the employee was a probationary employee. Staff C called the human resources department about the plan to terminate the employee. No investigation was done about the incident by the hospital since the employee was in his/her probationary period. Staff C was not informed of the human resources manager's investigation findings.
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9. On 3/30/2016 at 4:45 PM the Senior Director of Human Resources (Staff F) was interviewed. The director stated ideally the surgical services manager and human resources staff should coordinate investigative findings.
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10. On 3/30/2016 at 10:15 AM the Pharmacy Manager (Staff D) was interviewed. The Pharmacy manager confirmed that his/her department was not notified at any time during Staff A's employment of any possible drug diverting behaviors regarding Staff A.
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11. On 3/30/2016 at 5:20 PM the above information was verified with Staff B, the Chief Nursing Officer and Staff E, the Chief Quality Officer.
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12. On 3/30/2016 at 10:15 AM the Chief Quality Officer (Staff D) was interviewed. He/She stated that the current process, as of February 2016, is that the Patient Safety Officer (Staff H) reviews all incident reports and makes referrals to involve other departments. At the time of the incident involving Staff A on 3/7/2012 this system was not in place.
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