Puget Sound Hospice

“Based on interview, observation, and record review, the agency failed to ensure that staff are knowledgeable on the state’s mandatory reporting procedures of known or suspected abuse and/or neglect of patients to the appropriate state authorities for 3 of 3 clinical staff (Staff #604, #605, and #606). Failure of the agency to ensure that staff are knowledgeable on the state’s mandatory reporting procedures could lead to delayed reporting of known or suspected abuse and/or neglect of patients to proper authorities. . References: WAC 246-335-625 Personnel, contractor, and volunteer policies. The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (8) Mandatory reporting: (a) Mandatory reporters shall report failure to comply with the requirements of chapters 246-335 WAC and 70.127 RCW to the department. The report must be submitted on department forms. Reports must be submitted within fourteen calendar days after the reporting person has knowledge of noncompliance that must be reported. (b) Mandatory reporters shall report suspected abandonment, abuse, financial exploitation, or neglect of a person in violation of RCW 74.34.020 or 26.44.030 to the department of social and health services and the proper law enforcement agency. Reports must be submitted immediately when the reporting person has reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred. Findings included: 1. Document review of the agencys policy and procedure (P&P) titled, “;Assessment of Possible Abuse/Neglect),” (Policy No. 2-035.3, undated) showed that the clinician will submit a verbal report of suspected exploitation, abuse or neglect to the Washington State Department of Social and Health Services hotline and other proper authorities. 2. During the home visits on 07/09/24, the Surveyor conducted interviews with the following staff members: a. At 1:15 PM, the Surveyor interviewed Staff #604 (a Home Health Aide) about the agency’s policy and procedure for reporting suspected abuse and/or neglect of a patient. Staff #604 was unable to correctly identify the state authority or hotline number to call. b. At 2:15 PM, the Surveyor interviewed Staff #605 (a contracted Registered Nurse) about the agency’s policy and procedure for reporting suspected abuse and/or neglect of a patient. Staff #604 was unable to correctly identify the state authority or hotline number to call. c. At 3:15 PM, the Surveyor interviewed Staff #604 (Registered Nurse) about the agency’s policy and procedure for reporting suspected abuse and/or neglect of a patient. Staff #604 was unable to correctly identify the state authority or hotline number to call. 3. On 07/10/24 at 9:30 AM, the Surveyor interviewed the agency Director of Clinical Services (Staff #601) about the agencys P&P on mandatory reporting of known or suspected abuse and/or neglect of patients. Staff #601 stated that staff receive training on proper reporting of suspected abuse and/or neglect during orientation and during annual review. .”

“Based on observation, interview, and record review, the agency failed to ensure that staff followed proper disinfection of non-disposable equipment and devices after providing patient care on 2 of 3 clinical staff (Staff #605 and Staff #606). Failure of the agency to implement a method of proper disinfection of non-disposable equipment and electronic devices after providing care puts patients, staff, and visitors at risks of contracting communicable diseases. . Findings included: 1. Document review of the agencys policy and procedure (P&P) titled, “;Standard Precautions,” (Policy No. 6-004.1, undated) showed that non disposable equipment or supply that are utilized during patient care will be disinfected by thoroughly wiping down with an organization approved disinfectant before use with another patient. Examples of non-disposable equipment include pulse oximeter, nylon BP cuffs, and stethoscope. 2. During the home visits on 07/09/24, the Surveyor observed the following: a. At 2:45 PM, after performing patient care, a Registered Nurse (Staff #601) failed to disinfect the electronic device before placing it in their pocket. b. At 3:45 PM, after performing patient care, a Registered Nurse (Staff #605) failed to disinfect the electronic device before placing it in their pocket and failed to disinfect the equipment used to obtain the patients vital signs before placing the equipment in the bag. 3. On 07/10/24 at 9:30 AM, the Surveyor interviewed the agency Director of Clinical Services (Staff #601) about the agencys P&P on disinfecting equipment and electronic devices after providing patient care. Staff #601 stated that the staff are trained during orientation and on annual review to follow infection control procedures including proper disinfection of electronic devices and equipment after providing patient care. Staff #601 also stated that the agency provides staff with disinfecting wipes, sanitizers, and personal protective equipment (PPE). .”