State approves plan of correction for SageWest Heath CareDec 29, 2016 By Kelli Ameling, Staff Writer
Problems discovered at the hospital involved equipment that was found unclean before and during surgeries, rooms that were not kept at the required humidity, sterilization of needles and more.
The Health Care Licensing and Survey Office through the Wyoming Department of Health has accepted SageWest Health Care's plan of correction.
The hospital, with locations in Lander and Riverton, had to submit the plan by Nov. 10 after it was found noncompliant during a site visit Oct. 19.
A report from the WDH showed the Oct. 19 visit was initiated to follow up on a complaint made in 2015 regarding sterile conditions at SageWest.
A first on-site visit occurred in May 2016.
After another complaint was registered, a second on-site visit was conducted in October.
The site visit outlined seven areas - including five reoccurring and two new issues - the hospital needed to improve upon.
The issues involved equipment that was found unclean before and during surgeries, rooms that were not kept at the required humidity, sterilization of needles and more.
The hospital submitted its plan of correction before the deadline of Nov. 10. The document was approved Nov. 23.
"This news is a positive step forward in our progress toward providing patients with the highest quality care," SageWest interim CEO Tracie Stratton said in a press release. "Quality and patient safety are our top priorities, and while I'm proud of the way our hospitals responded to the issues ... our goal is to always give our patients the best experience possible. We are privileged to serve our friends and neighbors in the Riverton and Lander communities and look forward to building upon the positive momentum today's announcement creates."
Plan of correction
The plan of correction states SageWest took "effective measures for mitigation of risks" and indicates the hospital has implemented a "performance improvement program effectively addressing uncorrected system failures."
Education, training, observations, oversight, record-keeping, behavior monitoring, feedback, consulting and documentation of required processes have all been included in the plan of correction to help address the issues listed in the original complaint.
To address the humidity problems listed in the findings, SageWest Health Care at Lander will replace temperature sensors, control valves, steam control valves, steam injection humidifiers and more.
The Riverton facility will see the replacement of a duct terminal reheat box, the connection of a new box to the existing medium pressure duct, improvements to the heating water coil, installation of an exhaust fan and more.
The hospital closed all operating rooms at both campuses to all elective surgeries Oct. 26 through Nov. 7 to address the issues with unclean medical instruments found before and during surgeries. The health-care system "systematically re-opened operating rooms based on the availability of instrumentation for at least two re-processed sets for each procedure."
"SageWest allocated two competent and qualified central sterile processing staff for each campus with both individuals working together on the steps of the process on Oct. 31," the plan states.
The hospital received approval for three "highly experienced" contract staff technicians for central sterile processing. Two of the technicians started work in late November, and a central sterile processing supervisor consultant arrived from another LifePoint facility and stayed for a period of time.
The company LifePoint owns SageWest Health Care at Riverton and Lander.
In order to validate that decontamination processes are successful, the plan of correction states instruments at the hospital were randomly selected and tested using protein swabs after going through the washer cycle. In addition, daily bacterial culture swabs and protein swabs were conducted through Dec. 8 on hard-to-clean instrumentation.
The hospital also noted it will use enhanced recruiting efforts from outside firms to assist in permanent candidate searches. SageWest will bring in infection prevention specialists to observe operations by Dec. 30, and an Association for the Advancement of Medical Instrumentation membership was purchased to enhance and reinforce the sterilization process at the hospital. Additional instruments and trays have been purchased, and the hospital has received guidance from the Wyoming State Epidemiologist on an ongoing basis since Oct. 19.
Finally, staffing patterns were reviewed each pay period to ensure staffing is not compromised in the departments where issues were occurring.
WDH spokeswoman Kim Deti said her agency will follow up with on-site visits at SageWest to ensure the facilities are maintaining compliance.
The goal, she said, is to work with the hospital to help keep it compliant with standards. However, Deti noted it is the facility's responsibility to maintain compliance.
If a facility does not remain complaint, it could lose its certification.
Deti said no one at the Health Care Licensing and Surveys Office could recall an incident in which a Wyoming hospital lost its certification as a result of the corrections process.
"Situations where we call for plans of corrections are not uncommon," she said.
SageWest Health Care spokeswoman Lindsey Anderson said in a press release that the hospital continues to be accredited through a joint commission, and that accreditation is acknowledged in a compliance letter from the Centers for Medicare and Medicaid Services.
"The hospitals are held to the highest quality standards in the country, and the health system's Medicare contract remains intact," Anderson said.
She noted that SageWest Health Care was recognized by the Mountain Pacific Quality Health organization, which is part of the Wyoming Infection Prevention Advisory Group, for achieving excellence in infection prevention in 2013, 2014 and 2015.
"SageWest received a 3-star rating from CMS this year for overall hospital quality," she stated, "which means the health system is in line with the national standards of care across the categories used to calculate the ratings."