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Inpatient - Individual Plan of Care, Initial Assessment & Reassessment WAC 246-320-345

Each hospital is to assure that ALL caregivers are aware of the patient’s general and individual needs so that care will be provided in a planned and consistent fashion. All caregivers will know the desired outcomes of care for the patient and provide care that focuses on attaining those goals or outcomes. The patient care plan needs to be useful for the patient and the caregivers, not the surveyor.

Citations reflect a failure by hospitals to:

• Establish a plan of care based on the patient assessment;

• Reassess the patient periodically to determine if the initial needs/problems were resolved or continued; or

• Reassess periodically to identify new patient problems needing different interventions according to a revised plan;

• Individualize patient plans of care when the patient has very obvious special needs outside a standard plan of care that may have been based on a single medical diagnosis, or single procedure.

Each hospital is required to conduct an ASSESSMENT of the patient at the time of admission. The purpose of an assessment is to assure the needs of the patient are identified, interventions and treatment are determined, and goals of treatment, or desired outcomes established. The patient is periodically reassessed and changes are made to the plan of care based on that reassessment. The assessment should have a standardized format for consistency of care. The plan of care for the patient may be standardized but there must be a system to identify individual needs of the patient if present and the plan of care must reflect the variations or additional non-standard needs.

Inpatient - Restraints  WAC 246-320-345(5)(g)

The requirement is that hospitals will have policies and procedures that address the use of restraints. The purpose is for hospitals to use restraints for a patient as a last resort, never as a convenience, and to use restraints to protect the patient from self-harm, or protect staff from harm. Restraint use is based on WHY the restraint is needed, not WHERE it is applied.

In the development of policies for use of restraints, hospitals are expected to follow the directions of their accrediting body such as the Joint Commission for Accreditation of Healthcare Organizations, JCAHO, the Osteopathic Accreditation Organization, OAO, or if a non-accredited hospital, the Medicare Conditions of Participation 42 CFR 482.13 Patient Rights. It is important to note that the accrediting organizations and Medicare Centers for Medicare/Medicaid Services, regulations for patient restraint use are similar but not identical.

The citations reflect a failure by hospitals to develop and implement complete policies for use of restraints or a failure to follow hospital policies for restraint. Specific examples include:

• Failure to define restraint devices versus safety devices;

• Failure to define a physical restraint versus a chemical restraint;

• Failure to define use of restraints for medical/surgical reasons versus use of restraints for emergent behavioral/psychiatric reasons;

• Failure to obtain appropriate orders for restraints;

• Failure to document specific less restrictive interventions attempted;

• Failure to document the reasons for the restraint;

• Failure to document the actual restraint used;

• Failure to periodically assess/reassess the patient to determine if restraints continue to be needed and/or if the patient physical needs and safety are met;

• Failure to remove the restraint as soon as safely possible;

• Failure to provide continuous face to face monitoring of patients in seclusion and restraint; or

• Failure to provide and document annual training for staff caring for patients in restraints.

In-Patient Blood Transfusions WAC 246-320-345(5)(o)

The requirement is that hospitals implement policies and procedures to guide staff in the preparation and administration of blood and blood products.

Hospitals are expected to base their policies and procedures on recommendations or guidelines of a nationally recognized organization such as the American Association of Blood Banks, or a laboratory accrediting organization such as CAP, (College of American Pathologists), or the local blood banks. In addition hospitals seek input from the hospital medical staff, laboratory director, and nursing staff.

Citations reflect failure by a hospital to follow established policies such as:

• Failure to verify patient identify with two persons;
• Failure to verify blood/blood product identification for the patient by two persons;
• Failure to document the assessment of the patient pre and post administration of blood/blood products;
• Failure to document initial, incremental and final vital signs;
• Failure to document patient reaction/non reaction to transfusion; or
• Failure to administer blood or blood product at the ordered infusion rate.

HR - Qualified/Competent Staff WAC 246-320-165

The requirement is that hospitals will ensure that qualified and competent staff is available to operate each department. Staff is defined as: Paid employees, leased or contracted persons, students and volunteers. Qualified is defined as: An individual or staff member who has met the requirements for a specific position or task by education, training experience, applicable licensure, law or regulation, registration, or certification consistent with the job description. This is evidenced by:

• A process of on-going skill/competency assessment;
• Opportunities for education and development;
• Periodic performance evaluation review;
• Provision of specialized training, education, and skill development for specific tasks or positions; and
• Orientation on general and department specific infection control measures.

The citations reflect:

• Failure to establish staff competency standards for specialized care areas; or
• Failure to ensure that licensed, certified or registered staff practice only within their scope practice.
• Failure by a hospital to provide and document staff competency for specialized duties, such as:
• The registered nurse administering/monitoring conscious/procedural sedation according to the January 2000 Nursing Commission Policy Statement for Registered Nurses Performing Procedural Sedation;
• Use of restraints; and
• Assessment and management of malignant hyperthermia.

Pharmacy - Prepare, Dispense, Administration WAC 246-320-285

The requirement is that hospitals assure that patient pharmaceutical needs are met in a planned and organized manner, and that hospitals comply with the Board of Pharmacy regulations for a hospital pharmacy license found in WAC 246-873.

The citations cover a variety of issues related to pharmacy services including:

• Failure to have an organized and systematic pharmacy service under the direction of a hospital pharmacist;

• Failure to have clear orders for medications which include parameters for dose, route, frequency and reasons for administration;

• Failure to monitor medication effectiveness or therapeutic levels;

• Failure to review and assure pharmacy approval of medication protocols, and/or pre-printed medication orders;

• Failure to authenticate medication orders according to policy;

• Failure to monitor for and remove outdated medications;

• Failure to label medications in syringes; and

• Failure to keep medications secure according to hospital policy.

For information regarding medication security, reference the Board of Pharmacy Opinion Statement on Medication Security in Hospitals.  Contact the Board of Pharmacy at 360 236-4825.

For information regarding medication order authentication, reference the Board of Pharmacy Position Statement for passive authentication of medication orders at the above number.

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Washington State Department of Health
Facility Services Licensing
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Olympia, WA 98504-7852
Phone: (360) 236-2905
Fax: (360) 236-2901 

Last Update : 11/20/2006 04:06 PM
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