HospitalInspections.org

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Based on observation, interview and review of the hospital's policy and procedures, the Critical Access Hospital failed to ensure that patient care supplies were not available for patient use beyond the manufacturer's expiration date.
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Failure to properly maintain supplies places patients at risk for infection and delays in treatment.

Findings included:

1. The hospital's policy titled, "Checking Outdated Supplies," Policy # 7050-20, reviewed and revised 08/18/17, stated that monitoring of outdates is performed on a monthly basis by Central Services, Material Management or department supervisors.

2. On 02/06/18 at 9:00 AM, during inspection of the West Wing Unit medication/supply room, Surveyor #9 found 3 green-top blood collection tubes that had expired on 06/17/17. These were discarded at the time of the inspection by the Director of Nursing (Staff# 901).

3. On 02/06/18 at 12:00 PM, during inspection of the Emergency Department, Surveyor #9 found 1 purple-top and 1 yellow-top blood collection tube that expired in 12/2017. These were discarded at the time of the inspection by the Director of Nursing (Staff# 901).



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Based on record review, interview and review of hospital policy and procedure, the Critical Access Hospital failed to ensure staff members performed blood transfusion procedures according to policy for 1 of 5 patients (Patient #901).

Failure to follow blood transfusion procedures according to acceptable standards of practice places patients at risk for transfusion reactions and complications.

Findings Included:

1. The hospital's policy titled, "Blood or Blood Derivative Administration," policy #8721-028, reviewed and revised 02/01/17, states the Transfusion Record should document the signature of the staff member who double checked the unit of blood with the staff member starting the blood transfusion.

2. On 02/07/18 at 3:00 PM, Surveyor #9 reviewed closed medical records for five patients who received blood transfusions. One of the five records, Patient #901, showed that the unit of blood was not prechecked by two staff prior to the administration of a unit of blood on 04/23/17.

3. This finding was discussed with the Director of Nursing (Staff # 901) at the time of the review and she agreed hospital policy had not been followed.

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Based on observation, document review, and interview, the Critical Access Hospital failed maintain hot water at a temperature that provides for the safety of patients.

Failure to ensure that hot water is maintained at a safe temperature places patients, staff, and visitors at risk of injury from burns due to scalding.

Findings included:

1. Record review of the hospital's policy titled, "Hot Water Supply," Policy #8431-008, reviewed and revised 08/15/17, showed that hot water for bathing and hand washing purposes shall not be above 120 degrees F.

2. Surveyor #6 used a digital thermometer to assess the hot water temperature and made the following observations:

a. On 02/06/18 at 10:15 AM, hot water at a sink in the conference room adjacent to the cafeteria was assessed at 140.1 degrees Fahrenheit (above the safe limit of 120 degrees Fahrenheit);

b. On 02/07/18 at 8:20 AM, hot water at the handwashing sink in patient room #104 was assessed at 130.7 degrees Fahrenheit (above the safe limit of 120 degrees Fahrenheit).

3. On 02/06/18 at 10:30 AM, Surveyor #6 interviewed the Plant Manager (Staff #602) about the hot water provided by the hospital. Staff #602 stated that he is currently working to resolve temperature control problems in the plumbing system.

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Based on document review and interview, the Critical Access Hospital failed to ensure that the governing body signed and approved the medical staff bylaws.

Failure to have governing body approval for medical staff bylaws risks ineffective and inadequate care of patients.

Findings included:

1. On 02/08/18 at 2:00 PM, Surveyor #9 reviewed the Medical Staff Bylaws which showed that the bylaws were to be reviewed at least annually or more often if deemed appropriate by the Medical Executive Committee.

2. The Medical Staff Bylaws were dated as last adopted and approved on 10/15/16 and the Annual Review signature page was blank. Surveyor #9 discussed this finding with the Executive Assistant to the Administrator (Staff #902), who stated that the bylaws had been reviewed but was unsure why the signature page was left blank.

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Based on review of hospital policies and interview, the Critical Access Hospital failed to ensure that policies are reviewed annually.
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Failure to provide annual review of hospital policies and procedures risks poor patient care outcomes.
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Findings included:

1. Review of the hospital's policy titled, "Policy Format and Compliance," Policy #8610-001, effective 01/01/18, showed that each department manager is responsible to ensure that policies for their department are reviewed annually.

2. During review of hospital policies on 02/08/18 at 1:00 PM, Surveyor #9 found that policies specific to the Social Services department had not been reviewed since 05/02/16. This included the following policies:

Social Services Philosophy and Standards
High Risk Criteria for Referrals to Social Services
Initial Assessments for all referred Patients
Social Work Ethics
Social Work Documentation
Referral to Social Services
Medicaid Applications
Resident Rights
Durable Power of Attorney
Complaints
Social Service Assessments in Long Term Care
Discharge Planning
Nursing Home Identification Screen
Financial Assessments for Admission to Long Term Care
Private Rooms
Issuance of Hospital Issued Notice of Noncoverage
Certification and Recertification of Medicare Beneficiaries
Issuance of "Important Message from Medicare" and "Detailed Notice of Discharge"
Determining Proper Notice of Non-Coverage to Issue to Acute Care or Swing Bed Patients
Departmental Fire Plan

3. At the time of the finding, the Administrative Assistant (Staff #902) confirmed that review of the Social Service policies was not up to date.

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Item #1 - Air Pressure Relationships

Based on observation and interview, the Critical Access Hospital failed to assure the proper air balance between a soiled utility room and the adjacent corridor.

Failure to maintain ventilation that establishes proper air pressure relationships puts patients, staff, and visitors at risk of infection from contaminants and pathogens.

Reference: ASHRAE/ASHE Standard 170-2008; Ventilation of Health Care Facilities, Table 7-1

Reference: Design Standards; American Institute of Architects (AIA) Guidelines for Design and Construction of Health Care Facilities 2006 ed., Table 2-1-2, Ventilation Requirements for Areas Affecting Patient Care in Hospitals and Outpatient Facilities.

Findings included:

1. On 02/06/18 at 9:20 AM, Surveyor #6 used a tissue (flutter strip) to determine the direction of air flow between the soiled utility room on the West Wing and the adjacent corridor. The flutter strip was drawn toward the corridor indicating the soiled utility room was under positive pressure with respect to the corridor, contrary to ventilation requirements.

2. At the time of the observation, Surveyor #6 interviewed the Plant Manager (Staff #602) about maintenance of air pressure relationships. Staff #602 stated that he did not know whether air pressure relationships had been monitored and did not know of a policy that addressed it.

Item #2 - Handwashing Sinks

Based on observation and interview, the Critical Access Hospital failed to provide dedicated handwashing sinks in required locations.

Failure to provide necessary handwashing sinks places patients, staff, and visitors at risk from infection due to cross contamination.

Reference: Guidelines for Design and Construction of Health Care Facilities, 6.2.2.2; 6.4.4.4

Reference: Guidelines for Environmental Infection Control in Health-Care Facilities, Recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 2003;

Findings included:

1. On 02/06/18 at 9:35 AM, Surveyor #6 observed there was no handwashing sink in the Soiled Laundry Sorting room in the maintenance/laundry building.

2. At the time of the observation, the surveyor interviewed the Plant Manager (Staff #602) about handwashing facilities for hospital staff. Staff #602 stated that he was not aware of the requirement but that handwashing sinks are available in other locations.

3. On 02/06/18 at 3:30 PM, Surveyor #6 observed there was no handwashing sink at the cafeteria tray line, where dietary aides plate and serve ready-to-eat food.

4. At the time of the observation, the surveyor interviewed the Dietary Manager (Staff #606) about handwashing during food service at the tray line. Staff #606 stated that dietary aides could use a handwashing sink in the food preparation area of the kitchen. The handwashing sink nearest to the tray line is through a doorway and around a corner; it was obstructed from use at the time of the observation.

Reference: Washington State Retail Food Code (2009 FDA Food Code 5-204.11)

Item #3 - Water Management Plan

Based on interview and document review, the Critical Access Hospital failed to develop and implement a water management plan designed to reduce the risk of Legionella and other water-borne diseases in the patient population.

Failure to develop and implement a hospital-wide water management plan puts patients, staff, and visitors at risk of infection from water-borne pathogens.

Reference: Centers for Medicare and Medicaid Services (CMS) Survey & Certification Letter S&C 17-30, subject line, "Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD)"- Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water.

Findings included:

On 02/06/18 at 10:30 AM, Surveyor #6 interviewed the Superintendent/Administrator (Staff #601) and the Plant Manager (Staff #602) regarding the hospital's water management program. The superintendent stated that the hospital had established a committee to work on the water management plan and is in the process of completing a schematic to identify areas in the building water system where pathogens have a potential to grow. The proposed water management plan's control measures did not include:

a) Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as disinfection level control and visual inspections.

b) Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained

Item #4 - Ice Machines

Based on observation, document review and interview, the Critical Access Hospital failed to maintain the ice machines in accordance with manufacturer's recommendations.

Failure to maintain ice machines places patients, staff, and visitors at risk of infection

Findings included:

1. Manitowoc Ice Machine S Model & Ice Beverage QuietQube Ice Machines Technician's Handbook, page 73 specifies cleaning/sanitizing must be performed a minimum of once every six months. Manitowoc S-Model AuCS Accessory (Automatic Cleaning System) Manual, page 3-4 specifies using the AuCS accessory is supplemental to regular cleaning and sanitizing. Periodic maintenance must be performed every six months.

2. Follett Symphony Ice Machine Ice and Water Dispensers Installation, Operation and Service Manual, page 12 specifies cleaning & sanitizing is required for delivery of clean, sanitary ice; cleaning procedures should be performed at least as frequently as recommended, and more often if environmental conditions dictate. Weekly cleaning of drain pan and drain lines; semi-annual cleaning and sanitizing of ice maker and dispenser hopper.

3. Record review of the hospital's policy titled, "Ice Machine Inspection," Policy #8431-032, reviewed and revised 08/15/17, showed that the ice machine will be inspected quarterly and annually, and refers to the manufacturer's annual cleaning instructions.

4. On 02/06/18 at 2:10 PM, Surveyor #6 observed standing water and algal growth in the drip pan and drain line of the Follett Symphony Plus counter-top ice and water dispenser in the dining room.

5. At the time of the observation, the surveyor interviewed the Dietary Manager (Staff #606) about cleaning of the ice machines. Staff #606 stated that dietary staff are responsible for cleaning the exterior of the machines. He did not know when it was last cleaned.

6. On 02/07/18 at 5:30 PM, Surveyor #6 inspected the Manitowoc floor model ice machine beside the dirty dish return outside the kitchen. The surveyor observed a slimy, yellow substance along the edge of the plastic ice chute.

7. At the time of the observation, the surveyor interviewed the Plant Manager (Staff #602) about scheduled cleaning of the ice machines. Staff #602 provided Follett Ice Machine Maintenance monthly checklists for August, September, and October 2017. He did not know whether there was a cleaning schedule or log for the Manitowoc ice machine.

8. On 02/07/18 at 5:45 PM, Surveyor #6 asked Staff #602 to take the Manitowoc ice machine out of service until it could be cleaned and sanitized. Staff #602 placed an "Out of Service" sign on the bin of the machine.

Reference: Washington State Retail Food Code (2009 FDA Food Code 4-601.11; 4-602.11)

Item #5 - Cleaning Patient Rooms

Based on observation, document review, and interview, the Critical Access Hospital failed to ensure that hospital staff followed infection control measures when cleaning patient rooms.

Failure to implement effective infection control practices places patients, staff, and visitors at risk of exposure to harmful pathogens.

Findings included:

1. Record review of the hospital's policy titled, "Hand Hygiene - CDC Guidelines," Policy #8740-4008, reviewed and revised 09/27/17, showed that all staff are to use hand hygiene techniques; always after contact with medical equipment/supplies in patient areas, and always after removing gloves.

2. On 02/07/18 from 12:10 to 1:20 PM, Surveyor #6 observed two members of the environmental services staff (Staff #607 and #608) perform a discharge cleaning of Patient Room #110. The observation showed that after Staff #607 wiped the patient bed with a disinfectant the surveyor noticed dried blood on the inside surface of a side rail.

3. At the time of the observation, Surveyor #6 asked Staff #607 and #608 whether they were finished cleaning the bed. Staff #607 stated that the bed was finished. The surveyor showed her the blood stain and Staff #607 re-disinfected the bed.

4. At 12:45 PM, Surveyor #6 observed Staff #607 collect clean linens for the patient bed in Patient Room #110 without performing hand hygiene. At the time of the observation, the surveyor asked Staff #607 to place the linens in the soiled linen hamper, wash her hands, and collect another set of clean linens for Patient Room #110.

Item #6 - Chemical Test Strips

Based on observation, document review, and interview, the Critical Access Hospital failed to provide a use-by date for chemical test strips available for use in reprocessing ultrasound transvaginal probes.

Failure to properly date-mark chemical test strips with a calculated use-by date places patients at risk of infection from ineffective disinfection of patient care equipment.

Findings included:

1. Record review of the hospital's policy titled, "Liquid "Cold" High-Level Disinfection," Policy #7050-12, reviewed and revised 08/18/17, showed that CIDEX OPA Chemical test strips will be replaced every 90 days or at Expiration of Strips, whichever comes first.

CIDEX OPA (a high level disinfectant) test strips instructions for use state, "...discard any unused test strips 90 days after bottle is originally opened."

2. On 02/07/18 from 1:35 to 1:55 PM, Surveyor #6 inspected the Radiology Department with a radiology technologist (Staff #603). The surveyor observed a container of Cidex OPA test strips with an expiration date of 03/28/18. No open or use-by date was noted on the product.

3. At the time of the observation, the surveyor interviewed Staff #603 about the test strips. Staff #603 verified that there were no indications of the open or use-by dates on the bottle of test strips. She stated that she did not have any information about reprocessing ultrasound probes and that the sonographer was not available.

Item #7 - Relative Humidity in Sterilization Room

Based on observation, document review, and interview, the Critical Access Hospital failed to assure the proper relative humidity for the sterilization room.

Failure to maintain proper relative humidity standards puts patients at risk of infection from compromised surgical supplies.

REFERENCE: Centers for Disease Control and Prevention, "Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, William A Rutala, PhD, David J Weber, MD MPH and the Healthcare Infection Control Practices Advisory Committee (HICPAC),"page 73.

Findings included:

1. Record review of the hospital's document titled, "Central Services Checklist for Monitoring the Prevention of Exposure to Cross Contamination," showed that the sterilization room humidity range should be 35 - 70 [expressed as per cent].

2. Surveyor #6 reviewed relative humidity data recorded December 2017 through the current date. The relative humidity recorded in the sterilization room was 20 [per cent] for each of the following dates: 02/08/18, 02/06/18, 01/25/18, 01/23/18, 01/18/18, 12/12/17, 12/08/17, 12/04/17, and 12/01/17.

3. On 02/07/18 at 2:30 PM, Surveyor #6 interviewed the Central Services Department (CS) Supervisor (Staff #604) and a CS Technician (Staff #605) about monitoring the temperature and relative humidity in the sterilization room. Staff #605 stated that the CS Department is aware that the relative humidity is too low.

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Based on review of hospital policy and procedure, and medical records, the Critical Access Hospital failed to ensure that verbal orders for medications were authenticated within 48 hours of receipt.
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Failure to do so creates risk that errors related to the verbal order process will not be corrected in a timely manner to prevent patient harm from medications.

Findings included:

1. The hospital's policy titled, "Medication Administration," Policy # 7170-22, updated 08/21/13, stated that verbal orders must be signed by a medical provider within 48 hours. Policy #7170-22 was replaced with Policy# 7170-704, also titled, "Medication Administration," reviewed and revised 02/01/17. Policy# 7170-704 did not address verbal orders being signed by a medical provider. Surveyor #9 discussed this finding with the Director of Nursing (Staff #901) on 02/07/18 at 3:00 PM. Staff #901 stated that it was hospital policy that providers sign verbal orders within 48 hours and was unclear why this information was not in the current policy.

2. On 02/07/18 at 3:00 PM Surveyor #9 conducted an open chart review on the record of a swing bed patient (Patient #902). Verbal orders were recorded on 1/31/18 at 9:30 AM and 3:00 PM, and on 02/01/18 at 2:30 PM. At the time of the record review these orders had not been co-signed by the ordering provider (Staff #903).

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Based on review of patient records, interview and review of hospital policy and procedures, the Critical Access Hospital failed to ensure that staff followed policy regarding patients who were placed in restraints for behavioral issues.
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Failure to follow hospital policy regarding restraints could lead to patient harm and violation of patient rights.
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Findings included:
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1. The hospital policy titled, "Use of Restraints in Acute Care & ER," Policy #8721-092, reviewed and revised 02/01/2017, requires that less restrictive alternatives should be attempted prior to restraint use; patients and their families should be informed of the reason for restraints; patients must be assessed at least once an hour while in restraints; every two hours restraints are to be released and toilet measures, food and fluid are to be offered.
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2. Surveyor #9 reviewed closed patient records and observed the following:

a. A closed record review of Patient #903, a 21 year old female who was admitted to the Emergency Department (ED) on 10/27/17 at 3:19 PM for possible overdose, showed that wrist restraints were applied at 4:05 PM. There was no documentation regarding use of less restrictive measures or an explanation to the patient or her family as to why restraints were applied. It was noted that restraints were assessed at every 15 minutes until the restraints were released at 12:00 AM. The nursing note does not record releasing restraints for range of motion, offering fluid or food, or toileting measures during the duration of the time the patient was in restraints.
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b. A closed record review of Patient #904, a 15 year old male who was admitted to the ED on 06/28/17 at 4:45 AM for altered mental status, showed that the patient was secured with 4 point restraints at the time of admission. There is no initial explanation to the patient regarding use of less restrictive measures. At 5:30 AM the patient was noted to be sleeping and had a 1:1 sitter. The patient remained in restraints until 9:30 AM. The nurse (Staff #904) gave an explanation of the reason for restraints at 7:45 AM when she attempted to release restraints. The patient was checked every 15 minutes but there were no documented attempts at range of motion, offering fluid or food, or offering toileting.
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c. A closed record review of Patient #905, a 48 year old male who was admitted to the ED on 11/02/17 at 8:40 PM following a motor vehicle accident, showed that the patient was noted to be uncooperative and was placed in wrist restraints at 8:50 PM. There was no documentation that less restrictive measures were attempted or that the patient was given an explanation for the use of restraints. The patient was removed from restraints at 9:45 PM.
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3. On 02/07/18 at 3:30 PM, Surveyor #9 discussed the findings with the Director of Nursing (Staff #901). Staff #901 stated that staff did not document on the required restraint flow sheet. The flow sheet guides staff through the required assessments and documentation.
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Based on interview, record review, and review of hospital policy and procedures, the Critical Access Hospital failed to ensure that staff members developed a care plan that includes timetables for meeeting treatment goals for each long-term care ("swing bed") patient, as demonstrated by 5 of 5 swing bed patient records reviewed (Patients #906, #907, #908, #909, #910).
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Failure to include measurable objectives, interventions, and timetables when developing and implementing comprehensive care plans risks deterioration of the patient's condition and health status.
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Findings included:
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1. The hospital's policy titled, "Care Plans for Swing Bed Patients," Policy #6221-006, reviewed and revised 02/01/17, stated that swing bed care plans are established for each patient upon admission and modified based on observation flow-sheets, fall risk assessments, and physician orders and diagnosis.
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2. On 02/07/18 at 2:00 PM, Surveyor #9 reviewed the nursing care plans for five swing bed patients (Patients #906, #907, #908, #909, #910). The care plans for each of the patients demonstrated goals to be attained, but did not document interventions or follow-up on frequency of interventions, or resolution of issues.
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3. On 02/07/18 at 3:00 PM, Surveyor #9 discussed the finding with the Director of Nursing (Staff #901) and she acknowledged the finding.

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Item #1 - Emergency plan for pharmaceutical supplies

Based on interview and record review, the Critical Access Hospital failed to develop policies and procedures that addressed provision of pharmaceutical supplies for staff and patients during evacuation or shelter in place emergencies.

Failure to develop and implement a plan that provides emergency pharmaceutical supplies places patients and staff at risk of ineffective care and medical treatment during emergency situations.

Findings included:

1. On 02/06/18 at 11:50 AM, Surveyor #6 reviewed the hospital's Emergency Preparedness Plan, revised 10/17, with the Superintendent/Administrator (Staff #601) and the Plant Manager (Staff #602). The policies and procedures did not include provision of pharmaceutical supplies for staff and patients in the event of an evacuation or shelter in place emergency.

2. An interview with Staff #601 at the time of the review confirmed this finding.

Item #2 - Alternative power source

Based on interview and document review, the Critical Access Hospital failed to develop policies and procedures that address alternative power sources during emergency situations.

Failure to develop and implement a plan that provides emergency power places patients, staff, and visitors at risk of exposure to unsafe temperatures and an unsanitary environment.

Findings included:

1. On 02/07/18 between 11:15 and 11:25 AM, the Deputy Fire Marshal reviewed the hospital's Emergency Preparedness Plan, revised 10/17. The plan did not include a requirement that emergency power generator must maintain the following required subsistence needs:

a. Temperatures to protect patient health and safety, and for the safe and sanitary storage of provisions,

b. Emergency lighting,

c. Fire detection, extinguishing, and alarm systems.

2. An interview with hospital staff at the time of review confirmed the finding.

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Based on interview and document review, the Critical Access Hospital failed to develop and implement a system to track the location of on-duty staff who are relocated during an emergency.

Failure to develop and implement a system to track the location of on-duty staff following a relocation risks staff not being accounted for.

Findings included:

1. On 02/06/18 at 11:50 AM, Surveyor #6 reviewed the hospital's Emergency Preparedness Plan, revised 10/17, with the Superintendent/Administrator (Staff #601) and the Plant Manager (Staff #602). The policies and procedures did not include a system to track the location of on-duty staff in the event of a relocation.

2. An interview with Staff #601 at the time of the review confirmed these findings.

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Based on observation, interview, and document review, the Critical Access Hospital failed to implement emergency power system inspection, testing, and maintenance requirements.

Failure to monitor and maintain the emergency generator places patients, staff, and visitors at risk of injury and unsafe conditions during a power failure.

Findings included:

1. On 02/07/18 at 11:20 AM, the Deputy Fire Marshal reviewed the hospital's Emergency Preparedness Plan, revised 10/17. The plan did not include the following required elements:

a. No battery back-up emergency lights in the ATS (automatic transfer switch) room.

b. No annual fuel quality test.

c. Weekly inspections not documented for the preceding three weeks.

2. An interveiw with hospital staff at the time of review confirmed the findings.