Clinical Issues

Select one of the topics for a description of the common deficiencies found during onsite hospital inspections.

If you'd like more information on the "clinical issues" below, email us with your specific request.

Patient Rights and Organizational Ethics (B-0385)

WAC 246-320-141 – Hospitals must: (2) Provide each patient a written statement of patients rights from subsection (1) of this section.

Problem Solution
Pamphlet or handout missing some patient rights identified in current state law. Ensure all patient rights listed under this WAC are included in the patient rights handout.
Not providing written information on patient rights Provide a written statement of patient rights to all inpatients and outpatients.
Not providing written information to inpatients and/or outpatients Provide a written statement of patient rights to all inpatients and outpatients.

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Pharmaceutical Services (B-1080)

WAC 246-320-211 – Hospitals must: (1) meet the requirements in chapter 246-873 WAC.

Problem Solution
Verbal orders not authenticated Ensure verbal orders for medications are authenticated within 48 hours.
Physician authentication of verbal/telephone orders not dated and/or timed Ensure physician's authentication of verbal orders are dated and timed in order to determine if practitioner is authenticating in timely manner
No written order for administered medication Ensure all drugs are administered only upon the order of a practitioner who has been granted privilege to write such orders.
Medications not administered according to physician order Ensure nursing staff administer medications according to physician order.
Missing date and/or time of order entry Ensure nursing staff administer medications according to physician order.

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Food and Nutrition – Policies and Procedures (B-1055)

WAC 246-320-201 – Hospitals must (6) adopt and implement policies and procedures for food service according to chapter 246-215 WAC.

Problem Solution
Hand hygiene Employees should wash hands prior to donning gloves; when switching tasks (i.e., between working with raw foods and ready to eat foods, cleaning and food preparation); or any activity which may result in contamination of hands.
Storing raw food items with ready to eat foods To avoid cross-contamination, raw animal foods must be kept separate from raw or cooked ready to eat foods during storage, preparation, holding and display.
Not maintaining appropriate holding temperature for hot and cold foods Food handling procedures must ensure that foods are stored, prepared, held and displayed at the proper temperatures as described in the Washington State Retail Food Code.
Not maintaining appropriate chemical concentration level for sanitizing solutions Chemical sanitizers for food contact equipment and surfaces must be prepared according to type and by manufacturer instruction sufficient to yield a 99.999 percent reduction of representative disease microorganisms of public health importance
Using non-pasteurized eggs Use pasteurized liquid, frozen or dry eggs or egg products in place of raw eggs when pooling eggs for use other than as an ingredient in baked goods.
Misuse of hand sinks Hand sinks can only be used to wash hands and for no other purpose. Dishwashing sinks are not to be used as hand sinks.

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Emergency Services (B-1680)

WAC 246-320-281 – If providing emergency services, hospitals must: (8) assure emergency equipment, supplies and services necessary to meet the needs of presenting patients are immediately available.

Problem Solution
Expired electrode pads stored on crash cart Ensure medications and supplies in emergency crash carts are not expired and are ready for patient use.
Follow facility policy for crash cart and defibrillator checks.
Expired medications in Malignant Hyperthermia Carts and crash carts Ensure medications and supplies in emergency crash carts are not expired and are ready for patient use.
Crash cart and defibrillator checks not completed according to hospital policy. Follow facility policy for crash cart and defibrillator checks.
Staff not trained to respond to a Malignant Hyperthermia event in areas where anesthetic gasses were used Ensure hospital staff is trained to respond to potential emergencies.
Missing date and/or time of order entry Ensure hospital staff is trained to respond to potential emergencies.

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Infection Control Program (B-0895)

WAC 246-320-176 – Hospitals must: (1) develop, implement and maintain a written infection control and surveillance program.

Problem Solution
Variety of hand hygiene issues Ensure staff members adhere to facility policy and procedure and CDC guidelines for hand hygiene.
Use of multi-dose vials for more than one patient – medication drawn into syringe in patient care area Ensure staff members are educated in and comply with Centers for Disease Control and Prevention's (CDC) "Safe Injection Practices.
Not wiping IV ports with alcohol prior to accessing port Ensure staff members adhere to policy and procedure and CDC guidelines for use of personal protective equipment when caring for patients in isolation precautions.
Not wearing personal protective equipment (PPE) properly Ensure staff members adhere to policy and procedure and CDC guidelines for use of personal protective equipment when caring for patients in isolation precautions.
No policy for cleaning equipment between patient use (computers, blood pressure machines, etc.) Develop and implement a policy and procedure for cleaning equipment between patient use.

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Management of Environment for Care (B-1965)

WAC 246-320-296 – (10) Physical environment - The hospital must provide: (b) plumbing with: (iii) cross connection controls meeting requirements of the state plumbing code.

Problem Solution
Lack of an approved physical air-gap or appropriate backflow assembly to prevent contamination of a potable water supply by any non-potable solid liquid or gas through backflow. Provide a physical air gap or approved backflow preventer at all sources of possible cross-contamination including but not limited to:
  • Hand-held shower wands
  • Chemical dispensers
  • Mop/utility sinks
  • Lab equipment
  • Ice machines

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Management of Information (B-0750)

WAC 246-320-166 – Hospitals must: (4) create medical records that: (e) have accurately written, signed, dated and timed entries.

Problem Solution
No physician's order for patient treatments. Ensure all medical record entries are accurately written, signed, dated and timed.
Physician's verbal orders entered into patient record inaccurately Ensure all medical record entries are accurately written, signed, dated and timed.
Physician's orders for drugs, tests and treatments not signed, dated and/or timed Ensure all medical record entries are accurately written, signed, dated and timed.

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Environment Management – Ventilation and Air Pressure (B-1975)

WAC 246-320-296 – (10) Physical environment. The hospital must provide: (c) ventilation: (ii) with air pressure relationships as designed and approved by the department when constructed and maintained with industry standard tolerances.

Problem Solution
Failure to provide appropriate air pressure relationships throughout the hospital risks the spread of infectious organisms from room to room or from “dirty spaces” to “clean spaces.” Maintain air balances within rooms as approved during facility construction review.
Ensure that rooms that undergo a change in use are ventilated according to industry standards including but not limited to:
  • American Institute of Architects (AIA)
  • American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE)
  • Association of Medical Instrumentation (AAMI)
Failure to provide adequate ventilation within the facility risks the presence of objectionable order or excessive condensation Maintain air balances within rooms as approved during facility construction review.
Ensure that rooms that undergo a change in use are ventilated according to industry standards including but not limited to:
  • American Institute of Architects (AIA)
  • American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE)
  • Association of Medical Instrumentation (AAMI)

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Hospital Responsibilities – Comply with Chapter 70.41 (B-0005)

WAC 246-320-111 – (1) Hospitals must: (a) comply with chapter 70.41 RCW and this chapter.

Problem Solution
Not posting nurse staffing schedule and nurse staffing plan in public area as required by RCW 70.41.420. Ensure hospital compliance with RCW 70.41.420 - Nurse Staffing Committee.
Ensure hospital compliance with RCW 70.41.430 - licensed hospitals must adopt a policy regarding methicillin-resistant Staphylococcus Aureus (MRSA).
Not forming a nurse staffing committee as required by RCW 70.41.420 Ensure hospital compliance with RCW 70.41.420 - Nurse Staffing Committee.
Ensure hospital compliance with RCW 70.41.430 - licensed hospitals must adopt a policy regarding methicillin-resistant Staphylococcus Aureus (MRSA).
No policy and procedure for screening for Methicillin-resistant Staphylococcus aureus for patients who enter the hospital Ensure hospital compliance with RCW 70.41.420 - Nurse Staffing Committee.
Ensure hospital compliance with RCW 70.41.430 - licensed hospitals must adopt a policy regarding methicillin-resistant Staphylococcus Aureus (MRSA).
Not screening all adult Intensive care patients for Methicillin-resistant staphylococcus aureus Ensure hospital compliance with RCW 70.41.420 - Nurse Staffing Committee.
Ensure hospital compliance with RCW 70.41.430 - licensed hospitals must adopt a policy regarding methicillin-resistant Staphylococcus Aureus (MRSA).

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Patient Care Services – Patient Plan of Care (B-1200)

WAC 246-320-226 – Hospitals must:(4) have a system to plan and document care in an interdisciplinary manner including: (a) development of an individualized patient plan of care, based on an initial assessment.

Problem Solution
Failure to follow facility policy and procedure for development of individualized, interdisciplinary patient plans of care. Develop an individualized, interdisciplinary patient plan of care for every patient.
Ensure plan of care includes patient problems identified by initial assessment.
No care plans in patient medical record Develop an individualized, interdisciplinary patient plan of care for every patient.
Ensure plan of care includes patient problems identified by initial assessment.
Plans of care did not include primary patient problems as identified by initial assessment Develop an individualized, interdisciplinary patient plan of care for every patient.
Ensure plan of care includes patient problems identified by initial assessment.

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Patient Care Services – Restraints/Seclusion (B-1170)

WAC 246-320-226 – Hospitals must: (3) adopt, implement, review and revise patient care policies and procedures designed to guide staff that address: (f) Use of physical and chemical restraints or seclusion consistent with Code of Federal Regulations (CFR) 42.482.

Problem Solution
Patients not released from restraints when restraint release criteria had been met Ensure policy and procedure for restraints contain all elements included in CFR 42.482.
Ensure staff comply with hospital policy and procedure for use of restraints.
No face-to-face evaluation completed by physician/LIP within 1 hour of patient being placed in behavioral restraints Ensure policy and procedure for restraints contain all elements included in CFR 42.482.
Ensure staff comply with hospital policy and procedure for use of restraints.
Criteria for removal of restraints at the earliest possible time not documented Ensure policy and procedure for restraints contain all elements included in CFR 42.482.
Ensure staff comply with hospital policy and procedure for use of restraints.
No documentation that lesser restrictive alternatives to restraints had been considered Ensure policy and procedure for restraints contain all elements included in CFR 42.482.
Ensure staff comply with hospital policy and procedure for use of restraints.
No physician's order authorizing the use of restraints Ensure policy and procedure for restraints contain all elements included in CFR 42.482.
Ensure staff comply with hospital policy and procedure for use of restraints.
Staff not trained in the use of restraints Ensure policy and procedure for restraints contain all elements included in CFR 42.482.
Ensure staff comply with hospital policy and procedure for use of restraints.
Patients in restraints not monitored according to facility policy Ensure policy and procedure for restraints contain all elements included in CFR 42.482.
Ensure staff comply with hospital policy and procedure for use of restraints.

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Infection Control – National Guidelines (B-0925)

WAC 246-320-176 – Hospitals must: (4) develop and implement infection control policies and procedures consistent with the guidelines of the Centers for Disease Control and Prevention (CDC) and other nationally recognized professional bodies or organizations.

Problem Solution
Lack of hand hygiene after removal of gloves and before moving on to another task Ensure staff adhere to facility policy and procedure and CDC guidelines for hand hygiene.
Open multi-dose vials used for multiple patients stored in anesthesia cart in the operating room Ensure staff educated in and comply with CDC “Safe Injection Practices.

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Infection Control – Barrier and Transmission (B-1005)

WAC 246-320-176 – Hospitals must: (5) assure the infection control policies and procedures address, but are not limited to the following: (p) Barrier and transmission precautions.

Problem Solution
Not wearing personal protective equipment properly (gowns, masks, gloves) Ensure hospital staff members are educated in the use of personal protective equipment and isolation practice.
Ensure hospital staff members comply with hospital policies and procedures for use of personal protective equipment and isolation practices.
Not wearing personal protective equipment when entering room of patient in isolation Ensure hospital staff members are educated in the use of personal protective equipment and isolation practice.
Ensure hospital staff members comply with hospital policies and procedures for use of personal protective equipment and isolation practices.
Patient not placed in isolation as required by facility policy Ensure hospital staff members are educated in the use of personal protective equipment and isolation practice.
Ensure hospital staff members comply with hospital policies and procedures for use of personal protective equipment and isolation practices.

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