HospitalInspections.org

Based on medical record review, policy and procedure review and interviews with administrative staff, the hospital failed to ensure there were physician's orders for the use of restraints. This affected 1 of 1 record reviewed with restraints and had the potential to affect all patients served by the hospital.

Findings include:

Policy: Restraint and Seclusion, date of revision 3/11

Policy:

" 1. Behavior management restraint/seclusion use is limited to emergencies in which there is imminent risk of harm to self and/or others...

Physician's orders:

1. Orders for restraint and seclusion must be written or verbally given by a license independent practitioner...

4. Orders for restraint/seclusion must contain the following elements:

* Date and time
* Reason for restraint/seclusion
* Physician signature, date and time...

5. The time limits for restraint and seclusion orders are as follows:

* For acute medical/surgical restraint up to 24 hours

* For behavioral management restraint:

1. Up to 4 hours for adults 18 years and older...

Monitoring:

1. The frequency of monitoring should be determined based on the assessed needs of the patient.

2. At a minimum, the following parameters are monitored and documented:

Vital signs (pulse, heart rate, blood pressure)- behavioral management restraint- every 15 minutes...

3. The following needs are provided for at least every 2 hours:

* Nutritional and hydration needs
* Removal of restraints and range of motion
* Elimination needs ."


Medical Record (MR) findings:

1. MR # 6 was brought into the emergency room 5/12/12 after a motor vehicle accident with a possible Head Injury and Intoxicated.

The patient was triaged at 1700 (5:00 PM) and found to be combative on arrival. Wrist restraints were applied at 1713 (5:13 PM). The patient received Ativan 2 mg ( milligrams) IM (intramuscularly) at 1710 (5:10 PM).

A restraint order form sticker was attached to the Orders Form for the Emergency Department with soft restraints and soft vest restraints marked, reason for restraints marked as safety, combative and confused.

There was no criteria for release included on the order and no time limit for the order.

The order was not signed by the physician and no date or time was on the order.

The restraint flow sheet documented the patient was restrained at 1700 (5:00 PM) with a vest restraint and right arm and left arm extremities. The activity documented at 5:00 PM was agitated, extremity flailing.


The restraint flow sheet documented the patient was restrained at 1800 (6:00 PM) with a vest restraint and right arm and left arm extremities. The activity documented at 6:00 PM was non-combative movement.

The restraint flow sheet documented at 1900 (7:00 PM) " restraints off".

Vital signs were recorded at triage, 5:00 PM and at 7:18 PM.

The vital signs were not monitored per policy and the documentation of the patient during restraint failed to follow the policy. The physician's orders were not complete and failed to follow policy.

In an interview with the Emergency Room Manager, Employee Identifier #3, on 2/20/14 at 8:25 AM, it was confirmed the restraint orders were not complete and the nurse failed to document on the flow sheet vital signs and assessment per policy.

Based on the recertification survey conducted 2/20/2014 and interview, the facility failed to have an organized, hospital-wide and documented system of quality assessment and performance improvement program. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to A 273 for findings.

Based on review of facility policy and interviews, it was determined staff failed to:

1. Document all data collected.

2. Ensure all departments were included in data analysis reporting.

3. Follow it's policy for continuous quality improvement to ensure patient care improvement and monitoring was performed and reported to the medical staff and governing body.

This had the potential to negatively affect all patients served by the facility.


Findings include:

Facility Policy: Quality Assurance
Subject: Quality Assurance Department Program

Definition: To ensure activities of department and services continue with the Quality Assurance (QA) Program and implement changes as necessary.

Procedure:

" 1. The QA Coordinator will complete an annual report for review by the Hospital QA Committee. The report will verify the ongoing assurance activities, the comprehensive involvement of all departments...care and clinical performance.

2. The Hospital QA Committee will review the QA report for the year and will identify components of the QA program that need to be instituted, altered or deleted for the future year. The report will be presented to the Medical Staff Executive Committee and to the Governing Board via the chief executive officer.

3. Each department and committee will complete the annual report of activities to the QA Coordinator...includes any indicators that were resolved, on hold or added...during the year..."

The surveyor requested the facility quality improvement documentation. Employee Identifier (EI) # 2, Administrator, presented the Medical Staff meeting documentation for 5 meetings conducted between January 2013 and January 2014. Documentation review included reports of the quarterly QA activity for 2 to 3 departments.

An interview was conducted on 2/20/14 at 9:15 AM with Employee identifier (EI) # 1, the Director of Nurses. EI # 1 reported the annual report of hospital-wide quality assurance activities had not been completed or reported to the Medical Staff Executive Committee and the Governing Board (chief executive officer) for 2012 and 2013.

This Condition of Participation is not met as evidenced by:

Based on review of medical records, policy and procedures, Alabama Board of Nursing Standards of Practice and interviews it was determined the nursing staff failed to:

1. Document wound measurements

2. Document specific wound care provided

3. Document wound assessments to include appearance of the wound/ wound bed, exudates, drainage, odor signs and symptoms of infection

4. Document the skin surrounding the wound

5. Document education to caregiver or patient related to wound care after discharge

6. Have orders for wound care provided.

7. Ensure nutritional assessment for the patients were completed

8. Document daily weights as ordered.

9. Perform and document vital sign monitoring according to facility policy for 2 of 2 patients receiving blood transfusions.

10. Obtain and document consent prior to a blood transfusion.

Findings include:

Refer to A 392 and A 409 for findings.

Based on review of medical records, policy and procedures, Alabama Board of Nursing Standards of Practice and interviews it was determined the nursing staff failed to:

1. Document wound measurements

2. Document specific wound care provided

3. Document wound assessments to include appearance of the wound/ wound bed, exudates, drainage, odor signs and symptoms of infection

4. Document the skin surrounding the wound

5. Document education to caregiver or patient related to wound care after discharge

6. Have orders for wound care provided.

7. Ensure nutritional assessment for the patients were completed

8. Document daily weights as ordered.

This had the potential to affect all patients served by the facility and did affect Medical Records (MRs) # 1, # 3, # 5, # 7, # 8 and # 9. This affected 6 of 9 medical records reviewed.

Findings include:

Alabama Board of Nursing Chapter 610-X-6
Standards of Nursing Practice

610-x-6-.13 Standards for Wound Assessment and Care

(1)" It is within the scope of a registered nurse or licensed practical nurse practice to perform wound assessments including, but not limited to, staging of a wound and making determinations as to whether wounds are present on admission to a healthcare facility pursuant to an approved standardized procedure..."

(2) " The minimum training for the registered nurse or licensed practical nurse that performs selected tasks associated with wound assessment and care shall include:
(a) Anatomy, physiology and pathophysiology.
(c) Equipment and procedures used in wound assessment and care.
(d) Chronic wound differentiation.
(e) Risk identification.
(f) Measurement of wound.
(g) Stage of wound.
(h) Condition of the wound bed including:
(i) Tissues
(ii) Exudates
(iii) Edges
(iv) Infection
(i) Skin surrounding the wound."

610-X-6-.06 Documentation Standards

(1)" The standards of documentation of nursing care provided to patients by registered nurses or licensed practical nurses are based on principles of documentation regardless of the documentation format.

(2) Documentation of nursing care shall be:
(a) Legible
(b) Accurate
(c) Complete. Complete documentation includes reporting and documenting on appropriate records a patient's status, including signs and symptoms, response, treatments, medications, other nursing care rendered, communication of pertinent information to other health team members, and unusual occurrences involving the patient."


Facility Procedure: Wound Care Procedure for Major Wounds revised 11/12

Purpose: To provide guidelines for good technique in doing wound care.

W. Document the treatment in the patient's chart with notation of status of wound, drainage, skin integrity, etc.

Policy: Skin Breakdown/ Pressure Ulcers Management of revised 07/07

" Guidelines:
The nurse will assess the skin and document frequently the following:
A. Anatomical location of the wound.
B. Dimensions and depth of wound (in centimeters).
C. Stage of wound.
D. Characteristics of wound base.
E. Presence or absence of undermining or sinus tract formation.
F. Exudate.
G. Odor.
H. Condition of surrounding skin.
I. Condition of wound edge.

Stage I: Nonblanchable redness (erythema) or bluish/black discoloration of intact skin that does not resolve in thirty minutes of pressure relief.

Objectives:
1. Prevent skin breakdown
2. Keep skin pliable
3. Prevent maceration
4. Prevent trauma (friction and shearing).

Treatment options:
1. Set up a two hour training (turning) schedule.
2. Do not massage reddened area.
3. Position off affected areas as much as possible.
4. Emollients.
5. Skin sealants.
6. Transparent adhesive dressing (Bioclusive)."

Policy: Management of Pressure Ulcers revised 11/12

Purpose: To manage impaired skin integrity as it relates to pressure ulcers.

Policy:
" I. Meticulous skin care and positioning...
II. Assess skin condition at least one time per shift and document.
III. Status and condition of pressure ulcers should be assessed upon admission and at every dressing change. Location, stage, type of wound, width, length, depth, exudate, odor, presence of necrotic or granulation tissue and condition of surrounding skin should be documented."

Medical Record findings:

1. MR # 1 was admitted to the facility 1/17/14 with diagnoses of Atrial Fibrillation, Urinary Tract Infection, Dehydration and Diabetes Mellitus Type II.

The Nutritional Screening Form was completed 1/17/14 with only one area marked, " Diagnosis: CHF (Congestive Heart Failure), HTN (hypertension), COPD ( Chronic Obstructive Pulmonary Disease), Acute Crohns, Anorexia, Cirrhosis, Anemia, CVA (Cerebrovascular Accident), Dehydration, Cancer, Renal Failure, DM (Diabetes Mellitus)." The form was signed by the Registered Nurse and marked, " Patient is not at nutritional risk."

MR # 1 had diagnoses of Diabetes Mellitus Type II, Dehydration, Low Potassium and Hyponatremia. The history of a poor living situation, poor medication compliance and the diagnoses indicate a need for a nutritional assessment.

In an interview 2/20/14 with EI # 4 at 9:10 AM and EI # 1, the Director of Nursing, the above information was confirmed. EI # 1 stated that they needed education with the nurses regarding the Nutritional Screening Form completion.


2. MR # 3 was admitted to the facility 12/5/13 with diagnoses of Urinary Tract Infection, Pressure Ulcer, Alzheimer's Disease, Dehydration and Dementia.

The Nutritional Screening Form was completed 12/5/13 with the following information, " Diagnosis: CHF, HTN, COPD , Acute Crohns, Anorexia, Cirrhosis, Anemia, CVA , Dehydration, Cancer, Renal Failure, DM." The form was signed by the Registered Nurse and marked, " Patient is at nutritional risk. Nutrition Assessment needed."

The patient's albumin was 2.7 on admission.

The patient's weigh on admission was 125 pounds and 70 inches height.

The physician ordered daily weights 12/5/13.

The CNA (certified nursing assistant) documented 12/6/13 at 2:06 PM under nutrition, " Lunch_ % (percentage) refused."

The nurse documented 12/6/13 at 2:53 PM, " Eats only about 1/2 of any food offered."

The CNA documented 12/6/13 at 5:54 PM under nutrition, "Dinner 50 %..."

The CNA documented 12/7/13 at 12:55 PM under nutrition, " Lunch_ % bites."

The nurse documented 12/7/13 at 2:25 PM, "Rarely eats more than 1/3 of any food."

The weights were not documented daily as ordered.

The nutritional assessment was not completed on the patient while hospitalized as requested on 12/5/13.

The physical assessment completed on admission 12/5/13 by nursing staff included documentation, " Skin condition: Fragile/thin, pressure wound location, stage one to sacrum approximately 1 inch in diameter."

The Braden scale assessment completed 12/5/13 included, " Activity: bedfast/confined to bed. Mobility: Very limited position changes. Intervention... turn q (every) 2 hours and PRN (as needed), moisture absorbent pads... use lift sheet."

There was no documentation of interventions being performed 12/5/13 or 12/6/13.

The nurses continue to document observation of the pressure area on the sacrum. No wound care was provided while the patient was hospitalized according to the nurse documentation.

The 12/9/13 Hospitalist progress note documented under plan, " Continue with wound care decubitus to NH (nursing home) today.

The patient continued to have a poor intake throughout the hospitalization and on discharge 12/9/13 back to the nursing facility the physician's orders included, " Dietitian to monitor calories, wound care nurse to eval (evaluate) and Rx (treat) decubitus ulcer."

In an interview with EI # 4 on 2/20/14 at 9:30 AM the above information was confirmed.

3. MR # 7 was admitted to the facility 7/30/13 with diagnoses of Traumatic Injuries from tractor accident, Puncture Wound to Groin, Hypomagnesium and Second Degree Burns to Left side of body less than 10%.

The pertinent history documented on admission included, " Has multiple abrasions to left side with blister type burns noted on left hip. Has a 5 cm (centimeter) puncture wound to left groin area with packing..."

The problem activity form from the medical record documented 7/30/13 at 1:30 AM, " Numerous abrasions noted to left side of body, has several reddened area noted to stomach. Has 2 large bruises on inner thighs. Puncture wound 5 cm long to left groin area. Open blister type wounds noted to left heel (2 & 1/2 cm) left posterior calf (5 cm). Multiple blisters of various sizes and shapes noted to left hip with 2nd degree burns. 3 cm scratch across left cheek... Dressing: damp to dry gauze packing left groin."

The initial assessment dated 7/30/13 at 1:45 AM by the nurse documented, " Packing intact to puncture wound left groin. See wound Flowsheet."

The wound flow sheet dated 7/30/13 at 5:05 AM documented, " Puncture wound left groin."

Physician orders written in the Emergency room prior to arrival to the floor 7/29/13 at 11:23 PM, " Irrigate left groin wound with 1/2 str (strength) H2O2 (hydrogen peroxide), 1/4 inch iodoform packing x 6 inch... dressing change daily."

An order was documented 7/30/13 at 11:09 AM, " Silver Sulfadiazine cream to burn area daily..."

The Medication Record page 2 of 3 documented, " Silver Sulfadiazine cream to burn area 1 application BID (twice a day)."

The physician's order was for one time a day not twice a day.

The nurse signed off on the Medication Record twice a day on 7/30/13, 7/31/13, 8/1/13, and one time 8/2/13 the day of discharge.

The nurses failed to document completing wound care in the integumentary documentation of assessments and treatments on the nurses notes.

The nurses note for 7/31/13 at 11:26 AM documented, " Dressing changed left groin puncture wound flushed as per MD (medical doctor) order and packed with iodoform; pt (patient) tolerated well."

There was no description of the wound, drainage, odor or measurement documented by the nurse for the wounds on 7/31/13.

The nurses note for 8/1/13 at 12:06 PM documented, " Dressing changed, dry and intact, drainage: small bloody amount...Pt's (patient's) left groin dressing change completed..."

The nurse failed to document descriptions of the different wounds and burns. The nurse failed to document which wound had bloody drainage. The nurse failed to document what wound care was provided to the patient.

The nurses note for 8/2/13 at 10:42 AM documented, " Dressing change to left groin area..."

The nurse failed to document what wound care was provided to the patient, a measurement, description, drainage or odor.

The patient was discharged home with her daughter 8/2/13, there was no documentation of education to the patient or caregiver regarding the dressing changes. There was no return demonstration of wound care provided by patient/caregiver.

While hospitalized 7/30/13 through 8/2/13, the nurses failed to follow the physician orders for wound care to the burns, abrasions and puncture wound.

The Nutritional Screening Form dated 7/30/13 was signed by the Registered Nurse and marked, " Patient is not at nutritional risk."

The form had no other data documented on the form. The patient had mutiple wounds, second degree burns, low magnesium and a urinary tract infection.

In an interview 2/20/14 with EI # 4 at 9:20 AM and EI # 1, the Director of Nursing, the above information was confirmed. EI # 1 stated that they needed education with the nurses regarding the Nutritional Screening Form completion and wound care.

4. MR # 8 was admitted to the facility 2/16/14 with diagnoses of Pancreatitis, Diabetes Mellitus Type II, Anemia and Diarrhea.

The Nutritional Screening Form was completed on 2/16/14 with the following information, " Diagnosis: CHF, HTN, COPD, Acute Crohns, Anorexia, Cirrhosis, Anemia, CVA , Dehydration, Cancer, Renal Failure, DM . The form was signed by the Registered Nurse. The nurse failed to mark if patient was at risk or not at risk.

There was no nutritional assessment completed on the patient although the patient had mutiple diagnoses complicated by the fact she remained on sliding scale insulin and was either NPO (nothing by mouth) or on clear liquids from 2/16/14 through 2/20/14 when she still remained hospitalized.

In an interview 2/20/14 with EI # 4 at 9:20 AM and EI # 1, the Director of Nursing, the above information was confirmed. EI # 1 stated that they needed education with the nurses regarding the Nutritional Screening Form completion.




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5. MR # 5 was admitted to the facility on 1/29/14 with diagnoses that included Congestive Heart Failure, Bilateral Heel Cellulitis, Dementia and Macrocytic Anemia.

The Nutritional Screening Form was completed 1/29/14 at 5:38 AM with 2 areas marked, "Diagnosis: CHF, HTN ,COPD, Acute Crohns, Anorexia, Cirrhosis, Anemia, CVA, Dehydration, Cancer, Renal Failure, DM and Poor PO (oral intake) and/or Poor appetite.... Patient is considered at nutritional risk if 2 or more criteria met...." The form was signed by the Licensed Practical Nurse. The screening tool did not include the patient's nutritional risk status.

The patient nutritional screening did reveal the patient was at nutritional risk. There was no documentation that a nutritional assessment was completed during the hospital stay.

Review of the 1/29/14 4:38 AM physician order entry revealed daily weights were ordered. On 1/29/14 at 6:43 AM, the patients weight was 49.9 kilograms. No additional weights were documented. Staff failed to follow the physician's order for daily weights.

Review of the 1/29/14 4:55 AM physician order entry included "...cover heel with tegaderm foam..."

The next physician wound order entry on 1/29/14 at 11:52 AM was to clean the left and right heel daily and apply silvadene cream. There were no physician orders for the specific cleaning solution to be used. There was no documentation staff attempted to clarify/obtain orders.

Review of the 1/29/14 6:00 AM wound assessment contained documentation "See Wound Assessment Flowsheet". There was no 1/29/14 wound assessment document.

Review of the 1/29/14 11:30 PM nurse documentation revealed the following: "...Pressure wound location: Duoderm intact to bilat. (bilateral) heels. Heel protectors on..." There was no physician order's for use of the duoderm. There was no documentation of when the duoderm was applied.

There was no wound assessment documentation for 1/29/14.

Review of a 1/30/14 3:30 PM nurse documentation entry included a 1 centimeter (cm) by 1.5 cm skin tear around the left heel, reported to the supervisor and triple ointment (triple antibiotic ointment) and bandaid placed on site. There was no physician's order for use of the "triple ointment".

Review of the 1/30/14 11:28 PM nurse documentation revealed tegraderm dressing intact to heels. The 1/29/14 physician's order was for silvadene cream to bilateral heels, not tegraderm. There was no documentation when the tegaderm was applied.

There was no wound assessment documented for 1/30/14.

Review of nurse documentation on 1/31/14 at 10:40 AM included "...redressed heels with silverdene (silvadene) and wrapped. There was no documentation if and with what cleansing solution the heels were cleaned with before silvadene cream was applied.

There was no wound assessment documentation for 1/31/14.

An amended 1/31/14 3:05 PM nurse documentation entry revealed report was given to personnel at the Health and Rehab and discharge orders and medication list faxed.

Review of the 1/31/14 3:49 PM Discharge Instructions documentation included the following:
Continuing needs are met by Health and Rehab (rehabilitation) with open areas to bilateral feet. Wound/treatment: Able to care for wounds/treatments was documented. There were no specific wound care instructions documented in the discharge information.

An interview conducted 2/20/14 at 9:00 AM with EI # 1 confirmed the above findings.


6. MR # 9 was admitted to the facility on 2/17/14 with diagnoses including Gastrointestinal Bleed and Anemia.

Review of the 2/17/14 7:53 PM nurse initial interview documentation included a Stage 4 sacral decubitus, 4.8 centimeters (cm) circular appearance, pink tissue and no eschar noted.

Review of the 2/18/14 hospitalist assessment and plan documentation included a "...Stage 3 sacral decubitus with saline gauze dressing orders..." Order entry on 2/18/14 at 1:51 PM revealed saline gauze dressing daily to sacral decubitus.

Review of the 2/18/14 11:10 PM nurse documentation included wound dimensions 8 cm x (by) 8 cm circular, dressing maintained, dry and intact. There was no documentation decubitus care was performed on 2/18/14.

Review of the 2/19/14 hospitalist assessment and plan documentation contained documentation "decubitus ulcers clean".

Review of the 2/19/14 9:05 AM nurse documentation revealed the following care provided: "...cleaned with normal (normal saline) packed with wet to dry saline gauze covered with abd (abdominal) pad and secured with paper tape..." There was no physician's order to pack the decubitus with wet to dry saline gauze.

An interview with EI # 1 on 2/20/14 at 9:05 AM confirmed the above findings.

Based on review of policy and procedure, medical record review and interview, it was determined staff failed to:

1. Perform and document vital sign monitoring according to facility policy for 2 of 2 patients receiving blood transfusions. This did affect medical records (MR's) # 5 and # 9 and had the potential to negatively affect all patients receiving blood transfusions at the facility.

2. Obtain and document consent prior to a blood transfusion. This affected MR # 5, 1 of 2 patients reviewed that received blood transfusions.


Facility Policy and Procedure:
Subject: Blood Administration
Date of Reviewed: 8/2012

Purpose:
To set guideline and to define responsibilities for the proper administration of blood components.
Policy:
"...1. Administration of blood must be meticulously monitored...No amount of checking is excessive when administering blood...
7. Consent ...is not required if the physician orders the blood transfusion for emergency purposes...
Preparing the Patient
1. Ensure that a signed informed consent is on the chart. Do not proceed with blood administration until consent is obtained...
Monitoring During Infusion
...Vital signs are taken immediately prior...within 15 minutes after initiating.. and every hour until 1 hour AFTER the transfusion has been discontinued...
Monitor the patient's temperature, pulse, respiration and blood pressure as indicated..."


Findings include:

1. MR # 5 was admitted 1/29/14 with diagnoses that included Congestive Heart Failure, Dementia and Macrocytic Anemia.

Review of the physician's documentation included an order on 1/29/14 4:43 AM to transfuse 2 units of PRBC's (packed red blood cells) each over 4 hours.

Review of the Blood Transfusion Consent document did not contain the patient/guardian or Power of Attorney signature. There was no documentation staff contacted the patient's family to authorize consent.

Review of the nurse vital sign monitoring documentation during transfusion of the first unit of PRBC's revealed vital signs were taken before transfusion (8:15 AM), 15 minutes after transfusion started (9:05 AM), at end of transfusion (12:35 PM) and 1 hour after transfusion end (1:35 PM).

There was no documentation the patient's vital signs were monitored hourly during the transfusion at 10:05 AM, 11:05 AM or 12:05 PM.

Review of the nurse documentation during transfusion of the second unit of PRBC's revealed vital signs were taken before transfusion (4:50 PM), 15 minutes after transfusion started (5:00 PM), at end of transfusion (9:05 PM) and 1 hour after transfusion ended (10:00 PM).

There was no documentation the patient's vital signs were monitored hourly during the transfusion at 6:00 PM, 7:00 PM and 8:00 PM.

An interview on 2/20/14 at 8:50 AM with Employee Identifier (EI) # 1, the Director of Nursing, confirmed the above findings.


2. MR # 9 was admitted to the facility on 2/17/14 with diagnoses including Gastrointestinal Bleed and Anemia.

Review of the 2/18/14 1:51 PM physician's orders include transfuse 2 units of FFP (fresh frozen plasma) and 2 units of PRC's (packed red blood cells).

Review of the nurse documentation during transfusion of the the first unit of PRBC's revealed vital signs were taken before transfusion (4:25 PM), 15 minutes after transfusion started (4:40 PM), at end of transfusion (8:40 PM) and 1 hour after transfusion ended (9:40 PM).

There was no documentation the patient's vital signs were monitored hourly during the transfusion at 5:40 PM, 6:40 PM or 7:40 PM.

Review of the nurse documentation during transfusion of the the second unit of PRBC's revealed vital signs were taken before transfusion (11:00 PM), 15 minutes after transfusion started 1:15 AM), and at end of transfusion (5:00 AM).

There was no documentation vital signs were monitored 1 hour after transfusion ended. There was no documentation the patient's vital signs were monitored hourly during the transfusion at 2:15 AM, 3:15 AM or 4:15 AM.

An interview on 2/20/14 at 9:04 AM with EI # 1, confirmed staff failed to follow it's policy for vital sign monitoring during blood transfusions.

Based on review of emergency room records and interview it was determined in 5 of 30 emergency room records the physician failed to document the time the patient was first seen.
This had the potential to affect all patients seen in the emergency room and in the facility.

Findings include:

1. MR # 611089 presented to the emergency department 1/10/14 with his parents with a complaint of eating dog feces.

The nurse documented triage at 12:27 PM.

The physician provided treatment to the patient but failed to document a time seen on the Emergency Physician Record.

2. MR # 609458 presented to the emergency department 12/20/13 with a complaint of Cystitis and Amenorrhea.

The nurse documented triage at 9:21 AM.

The physician provided treatment to the patient but failed to document a time seen on the Emergency Physician Record.

3. MR # 609525 presented to the emergency department 12/20/13 with his parents with a complaint of a spider bite to his neck.

The nurse documented triage at 7:35 PM.

The physician provided treatment to the patient but failed to document a time seen on the Emergency Physician Record.

4. MR # 610626 presented to the emergency department 1/6/14 with a complaint of overdose of drugs.

The nurse documented triage at 8:56 PM.

The physician provided treatment to the patient but failed to document a time seen on the Emergency Physician Record.

The patient was admitted to the hospital.

5. MR # 610093 presented to the emergency department 12/30/13 unresponsive per spouse after severe vomiting yesterday.

The nurse documented triage at 7:20 AM.

The physician provided treatment to the patient but failed to document a time seen on the Emergency Physician Record.

In an interview with Employee Identifier (EI) # 3, the Emergency Room Manager on 2/20/14 at 8:15 AM, she confirmed the above information.

Based on observation, CDC (Centers for Disease Control) safe practices for use of multi-dose vials and interview with facility staff it was determined the facility failed to ensure all medications and biological's available for patients were not expired. The facility failed to ensure all multi-dose vials were labeled with the date opened. This had the potential to affect all patients served by this facility.

Findings include:


CDC- Multi-dose vials- Safe Practices last updated 2/9/11

Questions about multi-dose vials:

4. When should multi-dose vials be discarded?

Medication vials should always be discarded whenever sterility is compromised or questionable.

In addition, the United states Pharmacopoeia (USP) General Chapter 797[16] recommends the following for multi-dose vials of sterile pharmaceuticals:
1. If a multi-dose has been opened or accessed (needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.


An observation was conducted on the nursing unit on 2/18/14 at 9:40 AM. The surveyor observed the following expired drugs or unlabeled drugs and supplies:


Nursing Drug Room:

Ten blue top vacuette tubes expired 5/2013
Five red top vacuette tubes expired 12/2013
Four purple top vacuette tubes expired 10/2013
Labetalol Hydrochloride injectable 100 milligrams (mg)/20 milliliters (ml), 20 ml bottle open, not dated.
Six Children's Acetaminophen Oral Suspension 160 mg/5 ml expired 1/31/14.
Two bottles Nitroglycerin 50 mg/250 ml expired 1/2014.
One 8 ounce can of Thick It, open, not dated.
Depro-Medrol 40 mg/ml, open, dated 4/5/13, greater than 28 days.
One bottle Nitrostat 0.4 mg tablets, open, not dated.

Nurse drug room medication refrigerator:
One open, not dated apple sauce container.
One vial Dialtiazem 25 mg/ml, open, not dated.
One bottle GI (gastrointestinal) Cocktail, open date 12/3/13, expiration date 1/1/14.
Novolin R (regular) 10 ml vial, open date not legible.

Nurse unit supply room -"Inservice Room":
Two 1000 ml bags 5 % (percent) Dextrose in Lactated Ringers Intravenous (IV) fluids, expired 6/2012.
Ten 1000 ml bags 5 % Dextrose in Lactated Ringers IV fluids, expired 7/2012.

An interview on 2/18/14 at 10:30 AM with Employee Identifier # 9, Registered Nurse, Charge nurse, present during the observations, confirmed the findings.

On 2/18/14 at 2:10 PM, an observation was made with Employee Identifier (EI) # 7, Registered Nurse, Surgery Department Head. In the endoscope room, the following items were observed:
Four spot-endoscopic markers, expired 12/2010
One tube of lubricating jelly, expired 9/2009
One 500 milliliter 0.9 % Sodium Chloride irrigation solution, expired 5/2012
One 16 ounce bottle Isopropyl Alcohol, expired 6/2012
One bottle Triad hand gel, expired 7/2007

EI # 7 removed and discarded the items during the 2/18/14 2:10 PM tour.

At 1:20 PM on 2/19/14 with EI # 8, Operating Room Scrub technician, an observation was made in Central Sterile. A cart, set up for clinic use by an Emergency Room physician, included one 400 gram jar of Silver Sulfadezene 1 % (percent) 3/4 full, open, not dated.

An interview with EI # 8 on 2/19/14 at 1:30 PM confirmed the above findings.

Based on United States Health Public Food Code 2009 regulations, observations and interview, it was determined the hospital failed to ensure food was stored in a safe and sanitary manner. This had the potential to negatively affect all patients.

Findings include:

United States Health Public Food Code 2009

3-501.17 Ready-to-Eat, Potentially Hazardous Food
(Time/Temperature Control for Safety Food),
Date Marking.
...commercially processed food open and hold cold
(B) Except as specified in ¶¶ (D) - (F) of this section, refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in
¶ (A) of this section and: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Pf and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety...
(C) A refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) ingredient or a portion of a refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest- repared or first prepared ingredient. Pf
(D) A date marking system that meets the criteria stated in ¶¶ (A) and (B) of this section may include:...
(2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under ¶ (A) of this section;
(3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under ¶ (B) of this section...

During a tour of the dietary department on 2/18/14 at 11:00 AM with the Dietary Manager, Employee Identifier (EI) # 11, the surveyor observed in the cooler:

A plastic wrapped opened package of turkey meat dated 12/30/13
A plastic wrapped opened package of Roast Beef dated 2/9/14
A plastic wrapped opened package of turkey with no date opened
An unidentified package of meat which was opened and not dated.

During an interview conducted on 2/18/14 at 11:10 AM with EI # 11, confirmed the items were not dated and labeled and the items should not be opened more than 3 days. All of the items were discarded.

Based on observations during a facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

The facility failed to maintain preventive maintenance on the equipment in the hospital, monitor equipment to ensure it was safe for patient use, maintain appropriate humidity and temperatures in the surgical suite and maintain weekly inspections on the generator.

This had the potential to affect all patients, visitors and staff in the facility.

Findings include:

Refer to Life Safety Code violations and A 701, A 724 and A726 for findings.

Based on review of Preventive Maintenance logs, observations and interview it was determined the facility failed to maintain preventive maintenance on the equipment in the hospital and maintain weekly inspections on the generator. This had the potential to affect all patients served.

Findings include:

A tour of the Emergency department was conducted by the surveyor 2/18/14 at 9:20 AM with Employee Identifier (EI) # 3, the Manager of the Emergency department. The surveyor noted multiple pieces of equipment in the emergency rooms with no preventive maintenance stickers or stickers dated from 2011 and 2012.

In an interview with EI # 3 at 10:00 AM she confirmed the Preventive Maintenance man, EI # 6 had been around but she did not know when the last visit was made.

The surveyor requested a list of preventive maintenance from EI # 5, the Maintenance Manager on 2/18/14 at 1:00 PM.

EI # 5 informed the surveyor on 2/18/14 at 3:00 PM that the Preventive Maintenance man would be in later with his paperwork.

On 2/19/14 at 12:05 PM, EI # 6 met with the surveyors and provided a list of preventive maintenance (PM) he had completed 2/18/14 trying to complete at least the OR (operating room) and the ER (emergency room).

The list provided had 17 pieces of Emergency room equipment PM had been completed on 2/18/14 and 5 pieces of OR equipment PM had been completed.

In an interview with EI # 6 on 2/19/14 at 1:00 PM, it was confirmed the PM's had fallen behind.

The Facility failed to meet the requirements for the operation of the generator as evidenced by no documentation of weekly inspections of the generator and no documentation of the monthly load testing of the generator.

In an interview on 2/18/14 at 4:00 PM with Employee Identifier # 5, the Maintenance manager confirmed the generator had been installed and in use since July 2013 and he did not have documentation of testing.




30952

On 2/18/14 at 9:55 AM on the nursing unit, the crash cart was inspected and observed by the surveyor. An interview, conducted at 10:00 AM 2/18/14 with Employee Identifier (EI) # 9, Registered Nurse, 2/18/14 charge nurse revealed the crash cart was to be checked by staff each shift ensure the cart was stocked.

The Emergency cart contained one Nitroglycerin Infision System tubing, expired 9/2013.

The Nitroglycerin Infision System tubing was removed from the crash cart by EI # 9.

Observations made on the nursing floor on 2/18/14 at 11:20 AM included the following:
Room 143, vital sign cart, Bio-med sticker inspection due 5/2013
Room 138, Intravenous (IV) Pump, Serial # (number) E29412, Bio-med inspected "12/2012", (due semi annually)
Room 131, IV Pump, Serial # E29411, Bio-med inspected "12/2012", (due semi annually)
Room 130, IV Pump, Serial # E37048, Bio-med inspected "9/2011", (due semi annually)

An interview, conducted 2/20/14 at 11:30 AM with EI # 1, the Director of Nursing, confirmed the findings above.


On 2/18/14 at 2:10 PM, an observation was made with Employee Identifier (EI) # 7, Registered Nurse, Surgery Department Head in the endoscope room: One Ohmeda 200 suction unit with no Bio-med inspection sticker found on the machine.

The following observations were made in Operating Room (OR) # (number) 1 and the Post Anesthesia Care Unit (PACU):

OR # 1:
One ArthroCare Quantrum Arthroscopy unit, Bio-med sticker documentation inspection due "9/2013".
One Bair Hugger Warming Unit Mode 505 with no Bio-med sticker inspection found on the unit.
One Spacelab patient monitor unit, Bio-med sticker inspection documentation due 10/27/13, (due semi-annually)

PACU Bay 2:
One portable vital sign monitor with no Bio-med inspection documentation found on the unit.

During an interview on 2/18/14 at 3:30 PM, EI # 7 confirmed the above.


On 2/19/14 at 1:15 PM with EI # 8, the OR Scrub Technician, an observation was made in the room containing the Sterrad Nix sterilizer. The surveyor observed 1 open box of Sterrad Chemical Indicators, # 250 strips, Lot # 131211-02, currently in use, expired 11/2013. There were 3 additional unopened boxes, expired 11/2013, available for use.

An interview with EI # 8 and EI # 7 on 2/19/14 at 1:20 PM confirmed the above observation.

Based on review of facility policy, observation, review of the crash cart checklist and interviews, it was determined the facility failed to ensure equipment was monitored to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Department of Pharmacy Policy and Procedure:
Subject: Emergency Carts
Date of Revision: 3/13

"...4. Cart Inspections:
b. Each department will inspect their emergency cart at least twice daily..."


Findings include:

On 2/18/14 at 9:55 AM on the nursing unit, the crash cart was inspected and observed by the surveyor. The crash cart checklist from December 27, 2013 to February 18, 2014 was reviewed. An interview, conducted at 10:00 AM 2/18/14 with Employee Identifier (EI) # 9, Registered Nurse, 2/18/14 charge nurse revealed the crash cart was to be checked by staff each shift to ensure the cart was stocked and functioning.

The documentation did not reveal the crash cart was checked on the following shifts:
1/2/14 7-3 shift
1/9/14 7-3 shift
1/13/14 7-3 and 3-11 shift
1/14/14 7-3 shift and 3-11 shift
1/23/14 3-11 shift
1/27/14 7-3 shift
1/28/14 cart not checked on any shift
1/29/14 11-7 shift and 7-3 shift
1/3014 3-11 shift
2/6/14 11-7 shift
2/12/14 7-3 shift
2/13/14 7-3 shift
2/17/14 7-3 shift

An interview, conducted 2/20/14 at 11:30 AM with EI # 1, the Director of Nursing, confirmed the findings above.

Based on review of facility policy, Humidity/Temperature chart documentation, observation and interviews, it was determined staff failed to maintain appropriate humidity and temperature in the surgical suite. This had the potential to affect all patients who enter the Operating Room.

Facility Policy:
Subject: Humidity and Temperature Checks/Air Exchange
Revised: 1/2013

Purpose: To adhere to OSHA (Occupational Safety Health Administration) requirements for engineering controls in the OR (operating room).
Procedure:
" Humidity and Temperature checks are monitored and recorded daily...The normal humidity range is between 40% (percent)-60%. The recommended temperature range is between 62 F (Fahrenheit)-73 F...If the surgical suite humidity...is outside the normal ranges, case will not proceed until normal ranges are met and maintained..."

During a tour of the surgery department 2/19/14 at 1:55 PM, OR suite # (number) 1, the Humidity/Temperature chart was observed. Documentation review revealed the following:
Temperature greater than 73 degrees Fahrenheit 1 day in April 2013Temperature greater than 73 degrees Fahrenheit 3 days in May 2013
Humidity greater than 60 % 1 day in May 2013
Humidity greater than 60 % 10 days in June 2013
Humidity greater than 60 % 13 days in July 2013
Humidity greater than 60 % 9 days in August 2013
Humidity greater than 60 % 7 days in September 2013
Humidity greater than 60 % 1 day in November 2013
Humidity greater than 60 % 1 day in December 2013

An interview was conducted on 2/19/14 at 1:59 PM with Employee Identifier (EI) # 7, Surgery Department Head, who validated the findings and reported no documented action was taken.

Based on review of CDC guidelines, policy, observation and interview the facility failed to follow an organized and documented system of Infection Control practice. The facility failed to document surveillance and trending of infections.

This had the potential to affect all patients served.

Findings include:

Refer to A 749 for findings.

Based on The Centers for Disease Control Guidelines for Hand Hygiene in Health-Care Settings, hospital policy, observation, review of infection control information provided and interview it was determined the infection control nurse failed to:

1. Identify potential hazardous situations

2. Educate staff

3. Develop surveillance tools and monitor for infection control

4. Follow it's policy on handwashing

5. Address information gathered for a one year project for infection control related to handwashing.

This had the potential to negatively affect all patients, staff and visitors in the facility.

Findings include:

www.cdc.gov
Morbidity and Mortality Weekly Report
Recommendations and Reports October 25, 2002 / Vol. 51 / No. RR-16
Centers for Disease Control and Prevention

Guideline for Hand Hygiene in Health-Care Settings
Recommendations for Hand Hygiene

"...C. Decontaminate hands before having direct contact with patients
F. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, lifting a patient)
I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient
J. Decontaminate hands after removing gloves..."


Policy: Infection Control Guidelines

Effective date: 07/00

" II. Purpose:

Aseptic technique should assure the production of a product free from any type of contamination. Several factors can affect an employee's aseptic technique.

These factors are:
1. Handwashing...

IV. Procedures

A. Handwashing
Proper handwashing is a critical element of aseptic technique that must be practiced if contamination is to be minimized. Prior to commencing preparation procedures, the preparer shall use the following technique:

1. Wash hands thoroughly for 10-15 seconds, using Chlorhexidine scrub and lukewarm water. Hands should be washed immediately prior to commencing preparation procedures, upon entering the sterile products room, any time the hands may have been grossly contaminated, or as often as needed.

2. Fingernails should be short...

3. The hands should be rinsed thoroughly under running water, allowing the water to run from wrist to fingertips.

4. The hands should be dried thoroughly with a disposable towel."


The surveyor requested information from Employee Identifier (EI) # 1, the Director of Nursing on 2/19/14 regarding the Infection Control Committee and minutes from the Infection Control meetings.

A review of the Infection Control Committee minutes dated 4/3/13 documented the meeting started at 1:00 PM and was concluded at 1:30 PM. One case of MRSA (Methicillin Resistant Staph Aureus) for the quarter was discussed and 0 cases of C (Clostridium)-Difficile.

The next meeting was 7/11/13 at 1:15 PM and concluded at 1:30 PM. Two cases of MRSA for the quarter both community acquired was discussed and 1 case of C-Difficile for the quarter.

The next meeting was 10/17/13 at 12:49 PM and concluded at 1:00 PM. Two cases of MRSA for the quarter both community acquired was discussed and 0 cases of C-Difficile for the quarter.

The next meeting was 1/9/14 at 1:00 PM and concluded at 1:15 PM. One cases of MRSA for the quarter community acquired was discussed and 0 cases of C-Difficile for the quarter.

There was no documented education regarding infection control prevention provided to the surveyors or evidence of surveillance tools being being used to trend infections.

On 2/19/14 at 1:05 PM, Employee Identifier (EI) # 1, the Director of Nursing provided to the surveyor a Hospital Hand Hygiene Observation Tool where data had been collected in 2013 related to handwashing.

The observation started January 2013 and continued through January 2014.
A total of 178 observations were conducted with Registered Nurses, Licensed Practical Nurses, Laboratory Technicians, X-ray technicians, Physicians and Nursing Assistants by Housekeeping staff.

Of the 178 observations 108 observations were non-compliant or 60 % of the staff failed to wash their hands per policy.

In an interview with EI # 7, the Infection Control nurse, on 2/20/14 at 11:05 AM the above information was confirmed.

EI # 7 was asked who observed the staff during the project. She stated that housekeeping staff observed and documented the findings.

The surveyor asked if the housekeeping personnel were educated for the observation of staff during hand washing. EI # 7 stated that she spent time with the housekeeping personnel assigned to do the observation. There was no documentation available concerning education to the housekeeping staff who documented the hand washing observations.

There was no documented plan to address 60 % of the hospital staff failing to follow the handwashing policy that was identified in the findings of the study.




30952

A medication pass observation was performed on 2/19/14 at 8:45 AM with EI # 10, Licensed Practical Nurse (LPN).

After entering the patient's room, EI # 10 performed hand hygiene and gloved. EI # 10 observed the patient's IV (Intravenous) site, then closed the lid on the soiled bedside commode. EI # 10 then removed her gloves and discarded. EI # 10 failed to perform hand hygiene after glove removal. EI # 10 then donned clean gloves, scanned patient's armband, monitored the pulse rate and administered medications.

During the above medication pass, EI # 4, Registered Nurse, Discharge Planner, entered the room to assess the beeping IV pump. EI # 4 performed hand hygiene in the patient's bathroom, donned gloves and assisted EI # 10, LPN, reposition the patient in bed. EI # 4 removed and discarded her dirty gloves and donned clean gloves. No hand hygiene was performed after glove removal.

After medication administration, EI # 10 checked the beeping IV pump, removed and discarded her dirty gloves, exited the room to the hallway. EI # 10 began documenting on the portable chart station. EI # 10 contaminated the portable chart station by failing to perform hand hygiene.

Based on review of medical records and interview it was determined the facility failed to:

1. Document a choice/ list of home health agencies being offered to patients/ caregivers referred to home health or hospice

2. Document discussion with known home health patients to ensure it was the choice of the patient to return to the same agency.


This had the potential to affect all patients referred for care after discharge and did affect Medical Record (MR) # 1, # 2 and # 3.


Findings include:

1. MR # 1 was admitted to the facility 1/17/14 with diagnoses of Atrial Fibrillation, Urinary Tract Infection, Dehydration and Diabetes Mellitus Type II.

On arrival to the emergency room 1/17/14 the ambulance staff stated that the patient's living condition was horrible, garbage, roaches and 15 dogs living in the house with her.

The floor nurse documented 1/18/14 that she spoke with an RN (Registered Nurse) at Ivy Creek Home Health who stated that they had already reported the patient's living conditions to DHR (Department of Human Resources). The nurse also stated that they will follow up on the situation.

There was no documentation in the medical record of the case manager, Employee Identifier (EI) # 4 spoke with the patient regarding her home health agency and no documentation DHR was notified by the hospital of the living situation.

The patient was discharged home 1/20/14 at 12:37 PM with Ivy Creek Home Health to follow.

In an interview with Employee Identifier (EI) # 4 on 2/20/14 at 9:10 AM she confirmed she called the Home Health Agency 2/19/14 and spoke with someone who stated that they did not report to DHR because the daughters went to the house and cleaned.

2. MR # 2 was admitted to the facility 12/22/13 with a diagnosis of Alcohol Toxicity.

On 12/23/13 at 6:08 PM the physician wrote an order to, " Discharge home with Home Health to evaluate fall risk and alcohol use."

A case management note was in the medical record dated as a late entry 12/26/13 at 11:40 AM:

" Prior to hospitalization patient lived with: family.
Patient mental status: alert and oriented, understands medical problems.
Coping style: other- patient states he realizes that he drinks to much at times and states he will watch it from now on. Patient states he would like for Ivy Creek Home Health to come and evaluate him and the fall risk at his home. Going home on 12/23/13. Contacted Ivy Creek Home Health and faxed information to office."

There was no documentation that Ivy Creek was the hospital's home health agency and no documentation a list was provided to the patient to choose an agency of his choice.

3. MR # 3 was admitted to the facility 12/5/13 with diagnoses of Urinary Tract Infection, Pressure Ulcer, Alzheimer's Disease, Dehydration and Dementia.

A case management note was in the medical record dated as a late entry 12/10/13 at 10:47 AM:

" Interventions required: Family meeting for discharge planning.
Plan: Provide resources/referral.
Notes: Patient being transferred back to...(Nursing home). Called daughter and received a DNR (do not resuscitate) status. Called... (at nursing home) and informed her of patient status and daughters request. Dr (Doctor)... said it would not be long... (nursing home staff) stated that they would talk to daughter about what hospice they wanted."

There was no documentation a list was provided to the patient/caregiver to choose an agency of choice.

In an interview with EI # 4 on 2/20/14 at 9:30 AM the above information was confirmed.

Based on observation and interviews, it was determined the facility failed to ensure equipment required for patient safety was available. This had the potential to affect all patients that utilized the Operating service.

Findings include:


On a 2/19/14 at 1:15 PM, a tour and observation of the surgery department was conducted. The surveyor requested to see the department tracheostomy set.

An interview at 1:20 PM on 2/19/14 with Employee Identifier (EI) # 7, Registered Nurse, Surgery Department Head, confirmed there was no tracheostomy (trach) set in the surgery suite or surgery department. EI # 8, Operating Room Scrub technician, reported the Emergency Department had a trach set.