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violations OVERLAKE HOSPITAL MEDICAL CENTER (Bellevue, WA) Department of Health by Facilities and Services LICENSING
Washington State Department of Health Facilities and Services conducts surveys every two or three years for hospitals and other places of accommodation for tracking violations of State health policy and safety at the facility per the Washington State Administrative Code (WAC). The Webmaster has ferreted out the cache of violations Overlake Hospital has been cited with during these "walk through" surveys by State inspectors that ONLY find things during these three and four day periods the facility planned for, and inspectors ONLY spot check files, patient records and facility maintenance on those few days. The violations listed here are considered the LEVEL 4 violations, or least urgent. Although, they are quite serious. The Webmaster has only posted level 4 violations here, but is still investigating level 1,2, and 3 violations. Violations in patient confidentiality, serious mishandling and administration of blood products, 42 fire code violations were found repeatedly, misuse of patient restraints and seclusion tactics, food preparation violations, patient data records and poorly documented or absent care plans, employee tuberculosis screening problems in 70% of files reviewed, controlled anesthesia drugs tamper accessible by anyone in obstetrical suites, narcotic charting was poor or absent and many other charges that were found in 100% of cases reviewed during these periods of time in February 2000, and May 2003. Follow-up checks also showed violations were still not addressed when required by law to do so. All this information is available to anyone to get (for a fee) from Public Disclosure. The Webmaster has condensed the findings here for use by the public.
Violation of WAC 246-320-205 Information management and record data
6/6 cases showed lack of accurate history of the patient's episode of care and produced inconsistent patterns of clinical documentation. Documentation in pencil could be erased, resulting in incomplete information. These portions generally referred to physicians orders.
Violation of WAC 246-320-345 Inpatient care plans and documentation
4/4 cases spot-checked on the state survey between 2-14-2000 and 2-17-2000 and 6 of 6 cases on the 5-22-2003 survey showed numerous care plan, documentations of care for patients admitted for more than 24 hours. Based on review of records, staff interviews, and review of patient care standards the facility failed to have a mechanism to plan and document care provided in an interdisciplinary and collaborative manner, and failed to document the development of an individualized patient care plan. *Note this is crucial because the course of treatment must be thought out and tracked, if not, mistakes can be fatal, and care discontinued.
Case Example #1
This Patient was admitted for a cardiac ailment and another illness, which was diagnosed after a biopsy (specific information is redacted due to privacy laws). The patient had concerns with pain, anxiety regarding diagnosis and future health needs. The Cardex (Kardex) plan of care form was blank under care interventions and problems (required by law.) When asked about the plan of care for this patient, the staff stated "there was no care plan".
Case Example #2
This patient as admitted for some kind of infection (unspecified due to privacy laws) and was receiving intravenous antibiotics and had no care plan in the record either, they just winged it.
Case Example #3
There was also no care plan at all in the record for a patient with some neurological impairment and some serious complaints about post-operative problem and permanent deficits.
Case Example #4
This patient had a Foley catheter post-surgery. There was no individualized plan of care or review of standard of care in the record for the post surgical care.
Violation of WAC 246-320-345 3b and 5g Inpatient Re-assessment and Use of Restraints
Facility failed to follow policy in 4 of 4 cases for revised care plans when patients are placed in restraints. And 4 of 5 patient records in for patients placed in seclusion and restrained show the facility to be in violation of their own policy and state requirements for restraint use. The type of restraints must be documented, timed and dated. Findings included 2 cases (#1 and #2 Examples) of patients who were put in restraints for 2 or 3 days while in critical care to keep them from pulling on tubes. When it appeared this was done more for staff convenience. Failure to document revised care plan in these cases with restraint use placed patients at risk for inadequate care and at risk for being restrained unnecessarily leading to serious deterioration of physical and mental conditions due to the traumatic restriction of movement. The staff confirmed that the use of restraints in these cases was not documented or included in care any plan. Policy requires a new order for restraints must be given every 24 hours to continue use.
Case Example #3
Patient record of a case who was admitted and placed in seclusion and in physical restraints contain no record of revised care plan that address the issues of requiring seclusion and/or restraints in this case. Staff interviews on 5-19-03 acknowledge the need for care plan revisions for patients who need restraints or seclusion (should be very rare use).
Case Example #4
Patient placed in restraints record shows no documented use for their need or any new orders to continue them as they were. Again, done for staff convenience. Initial order logs date of original order, but no time.
Case Example #5
Patient admitted to behavior unit was placed in physical restraints and seclusion. But, the record shows seclusion/restraint flow sheet had not been completed. It only showed medication review. The record also did not state why seclusion was indicated nor show any less traumatic alternate interventions were considered. The restraint use education form was uncompleted. The narrative report states "the patient was agitated, hearing voices, unable to follow directions, punching mattress, kicking door, yelling and threatening while in a quiet room". Patient was then placed in a locked seclusion room for "staff and patient safety" due to "foul and abusive language" and failed "to contract for safety". Yet no documentation exists that leaving this patient in an open unlocked room was ineffective nor did the record show patient was a risk to staff. This creates a false imprisonment issue and again shows the staff used most aggressive measures to quiet a young patient. This case lacked the signature and name of the assessing nurse (presumably to avoid any questioning if a complaint was launched).
*Note Overlake staff psychiatrist John Dippel MD was charged with having sex with a patient during this same time frame, 5-20-03 and his license summarily revoked. Dippel attempted to relinquish medical license prior to the state board being able to file charges against a licensed professional (himself) "so the board would have no jurisdiction over him". He wasn't fast enough.
WAC 246-320-345 5o. Inpatient preparation and Administration of Blood products
6 of 6 inpatient records of blood transfusions reviewed show the facility failed to follow policy and procedure for their administration. This places patients at extreme risk for adverse reactions to blood transfusions and delays in recognition of adverse reactions. Infusing blood too rapidly can result in fluid overload and increase severity of any reaction incurred. Allowing a unit of blood to hang for extended period of time also increase microbial growth risk and serious complications to occur. Blood should be given over 1-1.5 hours or up to four hours per unit unless a different rate is ordered. Blood transfusion must begin within 25 minutes of blood received from the lab. The policy states also that blood must be checked first by 2 nurses against the wristband of the patient. Findings include violations:
Case Example #1
Transfusion on 2-25-03 indicate 2 nurses checked the blood 35 minutes apart, and this also documented the blood was obtained from the lab at least 35 minutes before the transfusion began. This case shows two very crucial procedural errors causing risk to the patient.
Case Example #2
A surgical patient received one unit of blood in just less than an hour, no order existed to show a more rapid rate to transfuse this patient was ordered, nor did clinical indications dictate such an order.
Case Example #3
A patient experienced excessive blood loss at the end of a procedure. Anesthesia ordered 2 units of packed red cells/blood to be given in the post anesthesia unit and one additional unit after results of a blood hematocrit test were in. Despite the physician note "See PACU notes" on the first transfusion vital sign data section, no evidence could be found of the blood administration in the PACU. The notes show the three units of blood were inconsistently documented. The 15 minute interval for vitals was ignored and the notes suggest the transfusion was given over 8 hours. The vital signs recorded were inconsistent with the fluid sheet documentation. The notes for this case also show overwritten data, confusing the data�s accuracy on this chart.
The policy on infusions of blood require vitals should be taken immediately before transfusion, 15 minutes after start time and on completion.
Case Example #4
Patient was given blood and no vitals were taken at the start, not until 35 minutes into the transfusion, a crucial error risking patient safety. Only vitals were on completion of transfusion.
Case Example #5
Patient received blood and only vitals taken were done hours before start time.
Case Example #6
Patient received blood and vitals were done only at 5 minutes after start, not at the appropriate intervals.
*Note other cases demonstrated similar findings of transfusion guidelines showing a repetitive pattern of many personnel practicing medicine well below the standard of care.
WAC 246-320-405 6a. and 9eii Fire/Life Safety and management of environment of care
Interestingly, at the time of this February 2000 survey, completed by Department of Health personnel RH Sodergren RS, and signed off no deficiency was found. Sloppy work by the state.
All 12/12 ICU beds in the hospital had no fire sprinklers in the room. There was a failure to install, replace or fix defective sprinklers in the rooms checked. The investigator missed this finding in 2/2000 only to go another 3 years with a fire hazard for the hospital's most vulnerable patients. However, in the survey of 6/25/2002 and the 5/2003, fire code violations were documented and still no implementation of proper safe environment was instituted. Staff stated they had no system in place to prioritize the needed corrections, so they didn�t. do anything about it.
All 25 ER beds in 5/2003 had no tamper resistant electric boxes as is required by law. This, also missed by inspectors in 2/2000. Injury and shock could result from this.
There were problems with room, shower and bath door locks in 16/29 patient rooms checked in 5/2003, also missed by 2/2000 surveyors for the state. If a fire alarm sounded, patients could be trapped in the bathroom and have no way to get out. In the psychiatric unit, 14 of 14 rooms had no positive door latches as required by law, also creating a risk of death by the increasing air pressure generated in a fire � a backdraft.
According to the Overlake in house fire alarm system records show that smoke detector maintenance was not done at all. Plant services engineering staff reported that the non-addressable type smoke detectors in the south wing, the administration wing, the laboratory wing and the E. Roc wing were not tested from April 2000 to April 2003. These findings were verified by Overlake's own administration.
There was also a failure to maintain two (2) feet of cleared area above storage may prevent fire fighting personnel from reaching all areas of a compartment room with water from a hose. An extreme risk for patients who are bedridden or even the newborns.
In 2002 and 2003 the state confidence survey at Overlake Hospital revealed 42 fire code deficiencies.
WAC 246-320-165 Tuberculosis screening of employees
7 out of 10 personnel records reviewed and staff interviews that annual Tb tests were not done on these personnel. Voluntary drop-in arrangements did not create a proactive route for these mandatory tests for EMPLOYEES. The tracking of testing was not working as required. There was no system in place to identify past due tests or secure results from those who failed to provide them.
WAC 246-320-245 Patient�s Rights and confidentiality
Based on interviews and observation the facility failed to ensure rights to privacy and confidentiality. This puts patients at risk for inadvertent disclosure of personal information without consent. The 5-22-03, survey found that the cardiac care rooms had video cameras in them focused on patient beds. Some of the screens were oriented so that any passer-by could see them.
During the 5-20-03 walk through of the short stay unit, down a back hallway out of nurse station view, an unattended cabinet labeled "old charts" was unlocked an accessible to anyone. Stacks of patient records were observed in the cabinets. Staff stated the records were of previous patients.
WAC 246-320-285 and WAC 246-873-080 2d Pharmacy services
Based on observation and staff interviews the facility failed to ensure pharmacy policy and procedures were followed regarding the controlling medications stored in the operating room suites of the childbirth center. The failure to monitor drugs in these unlocked controlled substances in accessible public areas places patients at risk of having surgical and anesthesia medications tampered with to the extent of placing them in physical danger. Staff stated the anesthesia carts were stocked with multiple legend drugs and confirmed these drugs were never lock up, and access was possible by the public without staff visualizing the cart easily.
*Important factoid discovered by the Webmaster at courthouse: Utley v. Overlake Hospital was a case filed by an RN employee who had been fired for diverting and improperly charting narcotics, according to her case file. Utley claimed she was fired because she was a black woman, and she felt there was a prejudicial racist element to her termination (Webmaster has only stated here what is public record). The nurse lost this case, because Overlake's defense... it couldn't have been a racially motivated firing because 5 other white nurses were fired previously for diverting narcotics! GOOOOOOOOO UTLEY! Call me, let's do lunch. Tell me more...
The 5-22-03 the state survey noted OHMC failed to ensure that documentation regarding drug effectiveness was accomplished for 5 of 8 patient records reviewed received drugs on an as needed basis. This places patients at risk for not having accurate documentation for care or follow-up care.
Case Example #1
Chemical restraints should be last resort measures, not for staff convenience to keep a patient quiet. This case concerns a patient who was ordered to have Ativan and Haldol (sedatives) 1-2 hours as needed, if necessary for agitation. Of the 14 doses given to this patient, only 2 administering doses documented any behavior that would warrant the drugs which is a chemical restraint to shut someone up. And effects of the drugs on the patient were not noted.
Case Example #2
An ER injury patient received 4 doses of Morphine in the ER found the documentation on this case for the rationale of this drug to be given only one time was needed. NO documentation of the effectiveness of the drug was noted. This could be a sign of narcotic diversion in theory. Patient got the saline, employee got high!
Case Example #3
Patient admitted for abdominal pain and had Ativan prescribed as needed. The medication record showed this drug was given 4 times in a small window of time. No documentation was found to show need or effects of pain assessment pre and post administration of the drug. The patient went to surgery. In the PACU after surgery, the patient received 3 doses Morphine and 2 doses Dilaudid for pain control without documentation of pain assessments pre or post surgery.
Case Example #4
A post surgical angioplasty patient in the PACU received 'droperidol' presumably for pain and discomfort, but the record lacked pre and post administration assessments of pain AND lacked any order for this drug at all.
Case Example #5
A surgical bone graft patient complained of a considerable difference in pain assessment in recovery period. And received pain drugs without assessments that differentiated the pain level or site and lacked patient's response to the drug or its effectiveness.
WAC 246-320-305 Food Nutrition Services
Based on observation and interview with kitchen manager, the hospital failed to adopt and implement policy that require the installation an indirect drain under food preparation areas. This causes a risk of sewage back up and potential contamination of fresh foods.
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