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Based on interview, medical record review, and review of the facility's policies and procedures the facility failed to assure written Physician orders were obtained for soft wrist restraints for Emergency Room (ER) Patient Identifier (PI) # 20, one of one medical records reviewed for restraints.

The findings include:

The Policy and Procedure "Restraint and Seclusion Introduction Policy" revised May 2010 documented, "Introduction ... Time limited physician order for an episode of restraint; ... Patient observation a minimum of every 15 minutes."

PI # 20 was admitted to the ER on 4/28/11 at 12:01 PM, with the diagnosis Psychiatric Issues. A review of the ER medical record revealed PI # 20 came to the ER by ambulance in handcuffs with local police escort. The ER medical record documented, " ... reports that pt (patient) was at school and began screaming and fighting ... in ER 3 and pt continued to scream and kick at staff."

The nursing general assessment documented at 12:10 PM revealed, "Wrist restraints to bilat (bilateral) wrists to prevent pt from harming self and others."

The ER medical record did not include a physician order for restraints.

During an interview on 7/14/11 at 8:15 AM, with the Chief Nursing Officer, Employee Identifier (EI) # 5, she verified there was no documentation of a physician order for the restraints.

Based on medical record review, interview, and hospital policy, it was determined the hospital failed to assure that, Emergency Room (ER) Patient Identifier (PI) # 20, 1 of 1 patient restrained was monitored every 15 minutes as directed in the hospital policy.

The findings include:

The Policy and Procedure "Restraint and Seclusion Introduction Policy" revised May 2010 documented, "Introduction ...Patient observation a minimum of every 15 minutes."

PI # 20 was admitted to the ER on 4/28/11 at 12:01 PM, with the diagnosis Psychiatric Issues. A review of the ER medical record revealed PI # 20 came to the ER by ambulance in handcuffs with local police escort. The ER medical record documented, " ... reports that pt (patient) was at school and began screaming and fighting ... in ER 3 and pt continued to scream and kick at staff."

The nursing general assessment documented on 4/28/11 at 12:10 PM revealed, "Wrist restraints to bilat (bilateral) wrists to prevent pt from harming self and others."

The next entries related to monitoring for restraints were on 4/28/11 at 1:00 PM, 1:30 PM, and 2:30 PM.

A review of the MR revealed on 4/28/11 at 3:07 PM the wrist restraints were removed and the patient was transferred to another hospital.

The ER medical record did not include monitoring every 15 minutes of the patient during PI # 20's stay in the ER.

During an interview on 7/14/11 at 8:15 AM, with the Chief Nursing Officer, Employee Identifier (EI) # 5, she verified there was no documentation of monitoring of PI # 20 every 15 minutes while restraints were in use.

Based on medical record (MR) review, review of hospital policies, review of the Alabama Nurse Practice Act and staff interviews, it was determined the hospital failed to ensure the initial nursing assessment was completed by a Registered Nurse (RN) for 6 of 20 medical records reviewed. This affected MRs # 12, # 13, # 14, # 15, # 16 and # 17. This had the potential to affect all patients served by the hospital.

Findings include:

Code of Alabama 1975
Nurse Practice Act
34-21-1. Definitions.

a. Practice of Professional Nursing. "The performance, for compensation, of any act in the care and counseling of persons or in the promotion and maintenance of health and prevention of illness and injury based upon the nursing process which includes systematic data gathering, assessment, appropriate nursing judgement and evaluation of human responses to actual or potential health problems..."

b. Practice of Practical Nursing. ..."Such practice requires basic knowledge of the biological, physical and behavioral sciences and of nursing skills but does not require the substantial specialized skill, independent judgement and knowledge required in the practice of professional nursing."

Hospital Policy

Admission Assessment # 1008
revised 4/2010

"Policy: Upon admission to the patient care unit, each patient will be assessed by a Registered Nurse to determine any immediate needs and appropriate assignment of the care and data collection. Delegation of specific aspects of data collection is based upon the patient's condition and the defined competencies of other patient care unit personnel...."

Standards of Nursing Practice #1030
Revised 5/2010

"Standard 1: The Registered Nurse shall use the nursing process to assess, plan, implement and evaluate patient care. Based on the nursing process, the practice of nursing shall be in compliance with hospital policies, protocols, and procedures. Quality, productivity, and responsiveness to the needs of patients, physicians and employees (staff) are foundational to this care...."


1. A review of MR # 14 revealed the patient was admitted on 4/18/11 with diagnoses which included Infected Decubiti, Chronic Myelocytic Leukemia, Severe Ascites and Splenomegaly secondary to Myelocytic Leukemia, Hypoalbuminemia and Factitious Hypocalcemia from that, Dehydration and Anemia of chronic disease related to Myelocytic Leukemia.

The nursing admission assessment was dated and signed on 4/18/11 at 12:43 PM by the Licensed Practical Nurse (LPN) only. There was no documentation that the patient was assessed by a Registered Nurse (RN). The RN entered a "RN Review" statement on 4/18/11 at 12:43 PM which read, "I have reviewed & agree w(with)/assessment".


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2. A review of MR # 15 reveals the patient was admitted on 1/3/11 with diagnoses including Urinary Tract Infection, Anemia, Paraplegia and Decubitus. The nursing admission assessment was dated and signed on 1/3/11 at 3:12 PM by the LPN only. There was no documentation that the patient was assessed by a RN. The RN entered a "RN Review" statement on 1/3/11 at 4:18 PM which read, "I have reviewed and agree w/above assess".

3. A review of MR # 12 reveals the patient was admitted on 12/5/10 with a diagnosis of Chronic Obstructive Pulmonary Disease. The nursing admission assessment was dated and signed on 12/5/10 at 3:57 PM by the LPN only. There was no documentation that the patient was assessed by a RN. The RN entered a "RN Review" statement on 12/5/10 at 12:05 PM which read, "I have reviewed and agree w/above assess".

4. A review of MR # 13 reveals the patient was admitted on 1/11/11 with a diagnosis of Congestive Heart Failure. The nursing admission assessment was dated and signed on 1/11/11 at 1:48 PM by the LPN only. There was no documentation that the patient was assessed by a RN and there was no "RN Review" statement noted in the record.



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5. A review of MR # 17 reveals the patient was admitted on 6/13/11 with diagnoses which included Status Post Fall with Fracture Left Patella and Fracture with Dislocation of Left Elbow. The nursing admission assessment was dated and signed on 6/13/11 at 4:32 PM, by the LPN only. There was no documentation that the patient was assessed by a RN. The RN entered a "RN Review" statement on 6/13/11 at 4:05 PM, which read, "I have reviewed & agree w/assessment".

6. A review of MR # 16 reveals the patient was admitted on 7/6/11 with diagnoses which included Acute Exacerbation of Chronic Obstructive Pulmonary Disease, Dementia and Depression. The nursing admission assessment was dated and signed on 7/6/11 at 7:45 AM, by the LPN only. There was no documentation that the patient was assessed by a RN. The RN entered a "RN Review" statement on 7/6/11 at 7:20 AM, which read, "I have reviewed & agree w/assessment".

During an interview on 7/14/11 at 10:00 AM, Employee Identifier (EI) # 5, Chief Nursing Officer, confirmed the physical assessments are suppose to be done by the RN. EI # 5 stated, "The LPNs can help obtain information but the ultimate responsibility for the physical assessment falls on the RN."

Based on observation, interviews, review of Industry Standards, and review of policy and procedures the facility failed to:
1. Administer medications to Observation Patient (OP) # 1 and # 2, also Medical Record (MR) # 19 and # 20 without cross contamination
2. Maintain Intensive Care Unit (ICU) Rooms without cross contamination.
3. This affected OP # 1, OP # 2, MR # 19, and MR # 20 and this had the potential to affect all hospital patients.

The findings include:
Policy and Procedure "Administration of Medications Nursing Services" Revised 5/20/10, Medications will be prepared immediately prior to administration."

Potter and Perry - Fundamentals of Nursing 6th Edition, Copyright 2005, page 852, "Administering Oral Medications ... 7. ... d. Prepare medications for one client at a time."

"Institute for Safe Medication Practices", October 7, 2004, "Examples of at- risk behaviors for healthcare providers- I. Patient Information 1. Preparing more than one patient's medication/ more than one medication at one time."

During an observation on 7/12/11 at 1:54 PM, revealed the Respiratory Therapist (RT), Employee Identifier (EI) # 16, gave a breathing treatment to MR # 19. EI # 16 took a multi-dose bottle of Albuterol Inhalant medication from his pocket. He administered the medication and put the bottle back in his pocket.

During an interview with EI # 17, another RT, on 7/13/11 at 11:40 AM, confirmed Albuterol treatments are given to multiple patients from the same bottle. EI # 17 also confirmed the RT's carry the bottle to multiple pt rooms to give treatments until the bottle is empty.

During an observation of the medication pass on 7/14/11 at 9:10 AM, the Registered Nurse (RN) EI # 13, was passing medications to 3 patients OP # 1 and # 2, and MR # 19. EI # 13 had placed 3 - 4 ounce cups with packaged medications inside the cups, in a small garden type container with handle. She carried this container into the rooms of all 3 patients' without cleaning the outside of the container prior to moving to the next patient. OP # 2 had a topical cream for rash on chest area and OP # 1 had respiratory wheezing with orders for an inhalant. The medications were exposed to other patient respiratory or possible rash contaminants.

During a tour of the ICU rooms on 7/12/11 at 11:45 AM, Room # 1 was observed to have different size Endotracheal Tubes (ET) taped on the area above the head of the bed. The bedside table contained multiple supplies such as sterile gloves, oxygen tubing, etc. During the observation on 7/12/11 of Room # 2, the ICU RN, EI # 17, verified the room had been cleaned. The surveyor found a suctioning tube paper without the tubing inside with other supplies in an open supply area. There were darkened spots in the bottom of the area containing the supplies. EI# 17 verified room # 2 had supplies left in it from the previous patient. EI # 17 stated the staff kept the ET tubes on the wall and the ET tubes are changed when an ET tube is used.

During a medication pass on 7/14/11 at 9:10 AM, the Registered Nurse (RN) Employee Identifier (EI) #13, was passing medications to 3 patients (Observation Patient (OP) #1 and #2, and Medical Record (MR) #19. EI# 13 had placed 3 - 4 ounce cups with packaged medications inside the cups, in a small garden type container with handle. She carried this container into the rooms of all 3 patients' without cleaning the outside of the container prior to moving to the next patient. OP # 2 had a topical cream for a rash on the chest area and MR # 19 had respiratory wheezing with orders for an inhalant. The medications were exposed to other patient respiratory and possible rash contaminants.

Based on observations, interviews, review of the facility's policies and procedures, and review of standards of practice, it was determined the facility failed to ensure the staff followed policies and standards for expired controlled drugs and use of single dose vials. This affected 2 of 2 observations of IV (Intravenous) flushes for Medical Record (MR) # 19, MR # 20 and this also affected Observation Patient (OP) #21's controlled medication. This had the potential to affect all patients in the hospital.

The findings include:

Policy and Procedure "Removal and Destruction of Medications" revised 7/9/10, "Purpose: To remove and properly dispose of out of date medications from the pharmacy, and other areas of the Hospital where medications are stored. Policy: Each month Pharmacy will remove medications expiring by the end of the month from the Pharmacy, Omnicell machines and any other areas of the hospital and nursing home that store medications. ... Expired controlled medications are held in the narcotic cabinet of the Pharmacy."

Policy and Procedure "Unit Inspection" reviewed 5/25/11, " Policy: All drug storage areas within this hospital will be inspected at least monthly by the Pharmacist. The purpose is to ensure proper storage of medications. ... Drugs shall not be kept in stock after the expiration date on the label ... General compliance with all applicable drug handling procedures."

Centers for Disease Control and Prevention "... Injection Safety Information for Providers ... Additional protection is offered when medication vials can be dedicated to a single patient. It is important that:
Medications packaged as single dose vials never be used for more than one patient ... "

1. During an observation on 7/13/11 at 8:40 AM, the locked "Patient Medication from Home" cabinet contained 3- 50 cc (cubic centimeters) IV (Intravenous) Morphine in 0.9% Sodium Chloride for OP # 21. These 3 bags had expired on 6/21/11. This medication had not been picked up by pharmacy per the hospital policy.

2. During a medication pass observation on 7/13/11 at 8:40 AM, 3- 10 ml (milliliter) single dose vials of 0.9% Sodium Chloride sitting on top of the Medication compartments in the medication room. The vials had blue type insertion device in the top of each bottle. Employee Identifier (EI) # 13, staff RN, verified the vials were used to obtain solution to flush multiple patients IV access devises.

During an interview on 7/13/11 at 10:20 AM, with a staff Pharmacist, EI # 14, verified the single dose medication vials did not contain preservatives therefore were for single use only.

Based on observations, facility policy review and staff interviews, it was determined the facility failed to assure that all medications available for patient use in the Outpatient Department and on the Nursing Unit were not expired. This had the potential to affect all patients.

Findings include:

Hospital Policies

#2122 Removal and Destruction of Mediations
Revised 7/9/10

"Policy: Each month Pharmacy will remove medications expiring by the end of the month from the Pharmacy, Omnicell machines and any other areas of the hospital and nursing home that store medications...."


#5004 Unit Inspection
Revised 5/25/11

"Policy: All drug storage areas within this hospital will be inspected at least monthly by the Pharmacist. The purpose is to ensure proper storage of Medications."

"Procedure:.....Drugs shall not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs shall be available for use...."

Outpatient Department:

During the tour of the Outpatient Department on 7/12/11 at 11:30 AM the following expired medications were observed in the double locked medication cabinet in the Outpatient nursing station:

(5) 1 milliliter (ml) vials of Dramamine 50 milligrams/milliliter (mg/ml) expired 6/11
(4) 1 ml vials of Dramamine 50 mg/ml expired 7/10
(4) 1 ml vials of Dramamine 50 mg/ml expired 12/10
(1) 0.25 mg/ml vial of Lasix expired 9/10

During the tour on 7/12/11 at 11:30 AM Employee Identifier (EI) # 9, Outpatient Nurse Manager, confirmed the aforementioned medications were expired.

During an interview on 7/14/11 at 8:40 AM, EI # 5, Chief Nursing Officer (CNO), confirmed the outdated medications should not have been in the medication cabinet.
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Nursing Unit:

During a tour on 7/12/11 at 10:50 AM, an observation of the medication refrigerator revealed a 1/2 full 5 ml bottle of Influenza Virus Vaccine had expired on June 30 2011.

The medication room had 9- 500 cc (cubic centimeter) bags of 5% Dextrose and 0.225% Sodium Chloride which expired on March 1, 2011.

The locked "Patient Medication from Home" cabinet contained 3- 50 cc IV (Intravenous) Morphine in 0.9% Sodium Chloride. These 3 bags had expired on 6/21/11.

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.

Findings include:

Refer to Life Safety Code violations.

Based on observation and interview with facility staff, it was determined the facility failed to:
a. ensure equipment was monitored to maintain safety of patients and staff
b. ensure that all medical supplies available for patient use in the Outpatient Therapy Department, Emergency Room, and Nursing Unit were stored properly and were not expired.

This had the potential to affect all patients.

Findings include:


Outpatient Therapy Department:
A tour of the outpatient therapy department was conducted on 7/13/11 at 9:00 AM an operable Hydro collator was observed with packs present in the supply area. The surveyor requested the temperature monitoring logs and the current temperature of the contents. There was no thermometer or temperature monitoring logs available for review.

Further observation of the supply area revealed a glass container of solution with a manufacturing label of "Barbicide Disinfectant". The container was filled with numerous medical instruments such as scissors, tweezers and hemostats. There was no label with solution or date of last change.

During an interview on 7/13/11 at 9:30 AM with Employee Identifier (EI) # 11, the Physical Therapy Director, he stated, "We don't have a thermometer or temperture logs". The surveyor then asked EI # 11, "What is solution in the "Barbicide Disinfectant" container and when was it last changed? He replied, "It's alcohol" and then confirmed with a co-worker that it was changed, "Last Friday". The surveyor then requested a policy for this process, and he stated, "We don't have one".

Further interview and observation was conducted on 7/13/11 at 9:45 AM with EI # 5, the Chief Nursing Officer, who verified the above.


Emergency Room (ER):
A tour was conducted on 7/13/11 at 8:10 AM in the ER. The surveyor found the following expired supplies:
Trauma Rm # 1:
Stat -Padz Adult Electrodes times (x) 1 pack (pk) expired (exp) 11/3/02
Zoll Pediatric Multi-Functional Electrodes x 1 exp 3/21/98
Tracheal Tube 8.0 x 2 exp 6/10
Tracheal Tube 5.0 x 1 exp 2/10

During the tour on 7/13/11 at 8:30 AM EI # 10, the ER Nurse Manager, confirmed the aforementioned medications were expired.



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Nursing Unit:

During a tour of the Nursing unit on 7/12/11 at 10:40 AM, revealed in the supply room just outside of the medication room contained a crash cart. The crash cart had packages of electrodes on top of the cart for easy use. The box of electrodes contained 1 package expired October 2009, 7 packages expired March 2011, and 4 packages expired May 2011. On top of this crash cart was also a 4 ounce tube of Lubricating Jelly with an expiration date of April 2010.

Based on record review and an interview, it was determined the hospital failed to assure the Qualified Therapeutic Recreation Specialist or an Activities professional had assessed 2 of 2 swing bed patients for appropriate activities. This affected Patient Identifier (PI) # 16 and # 17 and had the potential to affect all Swing- Bed patients.

Findings include:

Policy and Procedure "Activity Program for Swing-Bed Patient's" effective 11/6/2008, "Procedure: ... 5. Documentation of swing-bed patient activities will be completed in the Swing- Bed Activities Flow Sheet by the activities assistant, nurse or social worker. The flow sheet includes type of activities, patient response, patient participation level and the patient's refusal of offered activities."


1. PI # 16 was admitted on 7/6/11 with diagnoses which included Acute Exacerbation of Chronic Obstructive Pulmonary Disease, Dementia and Depression.

The Activity Assessment was conducted by the LPN (Licensed Practical Nurse) and the interest was identified as "Family, home" and in room Activities as "Visitors". There was no documentation the Qualified Therapeutic Recreation Specialist or an Activities professional had assessed this patient or monitored PI# 16's activities during the 6 day swing bed stay.


2. A review of MR # 17 reveals the patient was admitted on 6/13/11 with diagnoses which included Status Post Fall with Fracture Left Patella and Fracture with Dislocation of Left Elbow.

The Activity Assessment was conducted by the LPN (Licensed Practical Nurse) on 6/13/11 and the interests were identified as "TV, phone" and "Approach: Provide in- room activity, Provide out of room activity, Group activity, encourage participation." This assessment did not address the patient was hard of hearing (HOH), what specific activities for in room or out of room activities, or if there was special activities available for the HOH.

The physical assessment on 6/14/11 by the Registered Nurse (RN) documented, "Pt (patient) extremely hard of hearing. Used paper and pen to communicate with pt."

There was no documentation the Qualified Therapeutic Recreation Specialist or an Activities professional had assessed this patient or monitored the patient activities during the 29 day swing bed stay.

An interview with Employee Identifier (EI) # 5, Chief Nursing Officer, on 7/14/11 at 8:30 AM, verified there was no documentation the Qualified Therapeutic Recreation Specialist or an Activities professional had assessed the swing bed patients for activities or monitored the activities for the swing bed unit.