HospitalInspections.org

Based on review of Medical Staff Bylaws, Emergency Room staffing schedule review, and employee interview, the facility failed to provide emergency care services under the direction of a qualified member of the medical staff.


Findings Include:


During an interview on 03/16/17 at 9:15 a.m. the Nurse Practitioner stated, "We do not staff physicians in the emergency room, only Nurse Practitioners. We use tel-med if we need a physician."


Review of the facility's Medical Staff Bylaws (approved 8/24/09) revealed, " ...f. The Emergency Services Staff shall consist of all Active Medical Staff Members. Each Active Medical Staff Member will serve as an ER Physician on a rotating on-call basis."


Review of the emergency room staffing schedule revealed only Nurse Practitioners are scheduled to work in the emergency room.


On 03/16/17 at 12:10 p.m. the Administrator confirmed that only Nurse Practitioners work in their emergency room.



During Exit Interview on 03/16/17 at 12:45 p.m. these findings were discussed. Nothing further was submitted for review.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure
the patient care environment was clean, orderly and safe for three (3) of three (3) days of survey.


Findings Include:


Observation of the Laboratory Department on 03/14/17 from 10:25 a.m. to 10:48 a.m. revealed:
1. A cart with supplies used to draw patient blood samples was stored in the visitor hallway just outside the laboratory entrance.
2. The entrance way to the laboratory department had no door.
3. The restroom used for drug screening had broken floor tile.
4. The blood bank area had a refrigerator that contained food.
5. Perishable items were stored on top of the staff refrigerator that was located across from the blood bank storage equipment.
6. The general laboratory station had multiple cardboard boxes stored on the floor, peeling paint on the ceiling and broken wall tiles.
7. All of the department door facings and frames had peeling paint.

During an interview on 03/14/17 at 10:50 a.m., the Laboratory Manager confirmed all observations. When asked if there was a process for maintenance and/or department repair, she stated, "Yes".


Observation of the Respiratory Department and the patient waiting room, made with the Respiratory Director on 03/14/17 from 10:55 a.m. to 11:05 a.m., revealed:
1. The entrance door to a respiratory supply room was located inside a patient waiting room. The signage taped on the door entrance read "Pulmonary Function Respiratory Equipment and Oxygen Storage" and "Please do not block this door". The door was not locked and had no security measure. Further observation of the respiratory supply room revealed the ventilator equipment, oxygen cylinders and other respiratory supplies were stored in the room. Multiple cardboard boxes were stored on the floor.
2. Multiple facility wheelchairs were stored inside the waiting room, the east and west wall had broken surfaces, and the entrance door frame and facing had peeling paint.
The Respiratory Director confirmed all observations and when asked if there was a process for maintenance and/or department repair, he stated, "Yes".


Observation of the Radiology Department on 03/14/17 from 11:05 a.m. to 11:25 a.m. revealed:
1. The general x-ray room had uneven flooring at the entrance door threshold and cardboard boxes were stored on the floor.
2. The patient restroom had broken floor tile.
3. The computed tomography (CT) room had peeling paint on the entrance door frame and facing, multiple cardboard boxes were stored on the floor, and two (2) feet of floor molding to the right of the entrance door was missing. The CT room had intravenous supplies and multiple bottles of contrast stored in an unlocked cabinet. The door to the CT room was unlocked and had no security measure. The CT Control Room door was open and contrast was stored in the warmer.
During an interview on 03/14/17 at 11:30 a.m. the Radiology Director confirmed a visitor could enter the CT room during a procedure and confirmed all observations made in the Radiology Department. When asked if there was a process for maintenance and/or department repair, she stated, "Yes".


Observations were made of the acute and/or swing bed medical nursing floor environment with the Administrator on 03/14/17 from 11:45 a.m. to 12:00 noon. These observations revealed Patient Rooms #8750, #8751, #8752, 8753, #8754, #8755, #8756, #8757, #8758, #8759, #8760, #8761, #8762, #8763, #8764, #8765, #8766, #8767, #8768, #8769, #8770, #8771, #8773 and #8774 had paint peeling off the entrance door facings and frames. All observations were confirmed by the Administrator. The Administrator stated that the facility had been remodeling the patient rooms over the past year and a half but had no estimated completion date at this time.


Observations, made of the Dietary Department with the Dietary Director on 03/14/17 from 2:00 p.m. to 2:30 p.m., revealed:
1. Cardboard boxes were stored on the floor in the dry storage area.
2. There was broken floor tile in the walkway outside the dry storage area.
3. There was missing floor tile in front of the range.
4. The food pantry outside of the kitchen had broken wall surfaces on the exterior wall and paint was peeling off the door facing and frame.
The Dietary Director confirmed all observations. When asked if there was a process for maintenance and/or department repair, she stated, "Yes".


Observations were made of the acute and swing bed area with the Maintenance Director on 03/16/17 at 10:45 a.m.. Observations revealed Patient Rooms #8752, #8754, #8755, #8759, #8760, #8761, #8767, #8770, and #8771 had paint peeling from an interior wall. All observations were confirmed by the Maintenance Director.


During an interview on 03/16/17 at 11:20 a.m. the Maintenance Director stated there was no written policy and procedure on environmental repairs other than the help desk ticket policy. He stated that visual rounds were made daily and if something needed to be repaired he would put it on the schedule. He also stated there were no current help desk tickets for the Laboratory, Radiology, or Respiratory departments, but there was one help desk ticket from the Dietary Department which had been received on 03/15/17 for repair to the pantry wall.


Review of the facility's "Radiation Safety" policy, revised in 2007, revealed: " ...4. Never allow anyone to be in x-ray room or in room when portable examination is taking place unless the person is protected by lead apron ...Safety Guidelines For Radiology Department, I. Mechanical Safety: ...4. Keep floor free of objects that could make patient fall (water, etc.) ...".


Review of the facility's "Storage of X-ray Records and Supplies" policy, revised 2010, revealed: " ...Contrast media and supplies ...are stored inside the cabinet with door closures ...".


Review of the facility's "Help Desk Ticket Policy", effective date November 2016, revealed: "Purpose: The purpose of this policy is to establish guidance on issuing work request to ...Maintenance by employees ...Procedure: 1. All ...Maintenance requests must go through the online ticket system. If someone contacts the ...Maintenance departments directly, they will be asked to put in a helpdesk ticket. 2. Tickets will be worked on in order of priority and within a reasonable time. Tickets will be updated with importance information for the convenience of all involved. 4. The assigned technician must confirm satisfactory completion with the user before closing the ticket. 5. After hours Maintenance tickets we (will) be worked according to severity as determined by the Maintenance Director. If ticket cannot wait until following business day, the on-call technician will respond accordingly ...".


Review of the facility's "Hospital Rules and Regulations", approved in March 2005, revealed: " ...Article V, Administrator, Section 1: The Board of Trustees shall elect and employee a ...Administrator who shall be the direct representative of the Board of Trustees in the management of the hospital ...Section 2: The authority and duties of the Administrator shall include: ...5. To see that all physical properties are kept in good state of repair and operation condition ...".



During Exit Conference on 03/16/17 at 12:45 p.m. findngs concerning environmental repairs, department maintenance/repair or storage of patient care supplies were discussed. Nothing further was submitted for review.

Based on temperature and cleaning log review, staff interview, manufacturer guideline review, and policy review, the hospital failed to ensure patient-care equipment is maintained in a safe operating condition.


Findings Include:


Review of the facility's January thru March 2017 Hydrocollator Temperature and Cleaning Log and Paraffin Bath Temperature and Cleaning Log revealed the last temperature checked for the Hydrocollator was completed on 2/18/17. There was no documented evidence of cleaning performed for the Hydrocollator and Paraffin Bath.


During an interview on 03/14/17 at 10:00 a.m. the Occupational Therapy Assistant stated, "The aide checks the temperatures only once a month, however we use the Hydrocollator every other day and the paraffin bath maybe twice a year."


Review of Tropic Heater User Manual revealed, "Caution ...Never adjust the thermostat too high. The thermostat is extremely sensitive and the slightest adjustment will alter the temperature several degrees. The recommended operating temperature is 160 degrees F to 165 degrees F (71 degrees C to 74 degrees C). The temperature of the water should be checked with a thermometer after every adjustment, before using the Tropic Pac. Always allow sufficient time for the water temperature to stabilize ...Maintenance ....the tank should be drained, cleaned, and inspected systematically at a minimum intervals of every two weeks."


Review of the facility's "Cleaning Hydrocollator" policy (revised 5/2013) revealed, "... the hydrocollator will be cleaned once a month or more often is needed, to maintain cleanliness of hot packs."


Review of the facility's "Cleaning Paraffin Bath Policy" (revised 5/2013) revealed, "...cleaning of the unit is to be done once a month or as needed when used excessively for that month."


During Exit Interview on 03/16/17 at 12:45 p.m. these findings were discussed. Nothing further was submitted for review.

Based on observation, staff interview and policy and procedure review, the facility failed to ensure that biologicals are properly stored in the Radiology Department on one (1) of two (2) days of survey.


Findings Include:


Cross Refer to C0220 for the facility's failure to ensure biologicals are properly locked and stored in the Radiology Department.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure the patient care environment was clean and orderly for three (3) of three (3) days of survey.


Findings Include:


Cross Refer to C0220 for the facility's failure to ensure the environment was clean and orderly.

Based on observation, staff interview, and policy review, the facility failed to ensure their medication policies regarding recognizing and monitoring expired medications is followed to ensure outdated drugs are not available for patient use.


Findings Include:


On 03/14/17 at 10:15 a.m. a tour of the nursing department was made with the Director of Nurses (DON). Observations revealed:
1. The storage area in the nursing station contained:
a. 23 cans of outdated Nutren 1.0 Nutritional Supplemental Feeding Solution with the expiration
date of 3/4/17.
b. 15 cans of Glucerna 1.5 Cal Nutritional Feeding with an expiration date of 2/1/16.
c. Nine (9) bottles of Thick-It with an expiration date of 12/29/16.
d. Five (5) bottles of Thick-It orange flavor with an expiration date of 11/17/16.
2. The Medication Room contained:
a. 25 vials of Hydroxyzine HCl one (1) milliliter (ml) single dose with an expiration date of 2/17.
b. Seven (7) individual tablets of Synthroid 100 microgram (mcg) with an expiration date of
10/16.
c. 11 Captopril 25 mg tabs with an expiration date of 2/17.
d. One (1) vial of Novolog Insulin mix 70/30 with an expiration date of 5/2016.
e. Three (3) Diltiazem Hydrochloride injection 25 milligram (mg)/5ml with an expiration date of
12/16.
3. The Crash Cart, located on the nursing floor, contained a 500 ml fluid bag of Dextrose 5% with an expiration date of 2/17 and 1000ml of Lactated Ringers 5% dextrose with an expiration date of 10/16.
4. Observation of the Surgery Medication revealed a 100mg/5ml multi-use bottle of Lidocaine 2% with an expiration date of 2/1/17.
The DON confirmed all findings concerning the expired medications.


Interview with the DON on 03/14/17 from 10:45 a.m.-11:00 a.m. revealed the pharmacy is responsible for checking the medications every month and re-stocking as needed. She stated that the nurses check for expiration before giving any medication.


During an interview on 03/14/17 at 11:20 a.m. with the Pharmacist stated that the pharmacy technician was responsible for checking all medications on the first of every month and restocking as necessary.


Review of the facility's "Pharmacy" policy (reviewed (3/1/10) revealed " ...4. When expired non-controlled medications are identified, the pharmacy aide will promptly remove the expired items for the distribution ...5. The pharmacist will check for expired controlled substances ...".


Review of the facility's "Pharmacy" policy (revised 3/1/2010) revealed, " ...1. The dot system will be utilized for visual recognition of expiration dates. 2. It is the responsibility of the pharmacy aide to review all medications;;;3. The pharmacy aide will develop and maintain specific colored "dot" stickers system ...".


During Exit Interview on 03/16/17 at 12:45 p.m. these issues were discussed. Nothing further was submitted for review.

Based on observation, staff interview, and policy review, the facility failed to ensure that outdated drugs are not available for patient use.


Findings Include:


Cross Refer to C0270 for the facility's failure to ensure outdated drugs are not available for patient use.

Based on observation, staff interview, and policy review, the facility failed to provide a facility-wide system for identifying and controlling infections and communicable diseases of patients and personnel.


Findings Include:

Observations made on 03/14/17 at 10:30 a.m. with the DON (Director of Nursing) revealed that PPE (Personal Protective Equipment) was hanging on each patient room door. When the DON was asked about the equipment she stated, "Since we have all ventilator patients or patients being weaned off the ventilator the PPE is for precautions. We don't have any patients on isolation at this time."


During an observation on 03/15/17 at 11:30 a.m. it was noted on several corridors that patient room doors had a colored "dot" placed on them. The dots came in different colors. Observation also revealed that visitors in several rooms where dots appeared on the doors were not wearing any PPE. Interview with Registered Nurse (RN) #3 during the observations revealed the colored dots were for identifying the isolation type of each patient. When asked what each color represented she presented a copy of "Colored Buttons" which read:
Green = Pseudomonas
Red = methicillin-resistant staphyloccus aureus (MRSA)
Yellow = Clostridium difficile (C Diff)
Blue = carbapenem resistant enterobacteriaceae & Vancomycin Resistant Enterococci (CRE&VRE)


Observations made with the Team Leader on 03/15/17 revealed:
1. At 12:15 p.m. RN #3 was observed exiting out of a patient's room which had a green dot (Pseudomonas) and a red dot (MRSA) on the door. She was pushing a computer on wheels (COW) out of the patient's room. As she was preparing to enter another patient's room she was asked why she took the COW into the previous patient's room and also when does she clean the COW. She stated she must scan the patient's identification bracelet at the bedside before she can give the patient medications and that the COWs are cleaned at night with the V 360+ solution. All COW's are stationed in the hallway and accessible to all employees.
2. At 12:20 p.m. Therapy Technician #2 was observed exiting a patient room with a wheelchair. The room door had a blue dot (CRE & VRE) and a red dot (MRSA) on the doorway. Occupational Therapist #1 was observed exiting a patient's room with an oxygen cylinder. The room door had a blue dot (CRE & VRE) and a red dot (MRSA) on the doorway. Both employees were observed taking the dirty equipment back to a clean area, but were advised not to before cleaning with Clorox. Both were observed cleaning with Clorox wipes.
3. Observation at 12:30 p.m. revealed a cleaning cart containing "Dispatch Wipes" which had expired on 11/28/16.
4. At 12:40 p.m. a phone call was made to the State Office for instructions regarding the facility's Infection Control issues.


During an interview on 03/15/17 at 12:50 p.m. both the Administrator and the Infection Control Nurse stated that the facility agreed to correct Infection Control issues today. They would see that all equipment was thoroughly cleaned appropriately. They also stated that all employees would be in-serviced regarding infection control techniques; appropriate cleaning methods; preventing cross contamination of the COWs - only the scanners, but not the COWs, are to be taken into patient rooms; and how to appropriately disinfect will be given to all employees today and to each employee that is not here before they can provide care. In addition, patient's family's are to be notified to see the nurse for proper PPE when entering the rooms and notification should be placed on the patient's door.


During an interview on 03/15/17 at 1 :00 p.m. the Respiratory Therapist revealed that all the vital sign machines and the COWs are placed in the Emergency Room during the night for disinfection.


Observation at 3:30 p.m. on 03/15/17 revealed all COWs and vital sign machines were being wiped down and cleaned with saniwipes and cleaned with infrared lights x 10 minutes according to manufactures instructions.


On 03/15/17 at 4:30 p.m. RN #5 was observed performing wound care for a patient. The patient's daughter was in the room, was not wearing any PPE or gloves, and was observed holding pressure on the bleeding wound with blood on her hands and running down her arms. This was brought to RN #5's attention. RN #5 moved to hold pressure on the wound and the daughter went to wash her hands in the sink. After RN #5 completed the wound care she discarded the bloody gloves into the trash can by the sink. She did not place any of the infectious waste in the Red Bag (infections waste) located adjacent to the sink for disposal. During an interview with RN #5 at this time, she revealed she was new to wound care and had been working home health. Charge Nurse, RN #4, confirmed her statement, "She is new and does not work back here, but I will make sure she follows all infection control policies."


On 03/16/17 at 9:30 a.m. documentation was received from the Administrator which reflected the in-servicing of all employees and a signed statement of all steps which were put into place to prevent any infection control breeches.


Review of the manufacture's instructions for infrared and disinfection of the V-360+ revealed "Position the V-360+ unit in an appropriate location to ensure line of sight exposure to the room's target surfaces. Ensure that all surfaces requiring disinfecting are exposed to the unit. Note that if the room is equipped with furniture, equipment and/or fixtures, it may be necessary to re-locate the V-306+ and run additional cycles to ensure proper disinfection of all target surfaces in the room."


Review of the facility's "Infection Control Policy - Cleaning Equipment" policy (dated 03/15/17) revealed "Policy ...All equipment that is used on more than one patient must be wiped down with hospital cleaner disinfectant wipe after each patient ...Procedure: ... 2. COWs will be left in the hallway and only the scanner will be taken into the patient's rooms. 3. The scanner will be wiped down with a hospital cleaner disinfectant wipe before leaving room... 5. All reusable equipment will be wiped down with a hospital cleaner disinfectant wipe before exiting the patient's rooms. The clean equipment will then be exposed to the ultraviolet light for ten minutes each night."



Review of the facility's "Handling of Biohazardous Waste" (revised 3/2015) revealed: " ...p.2. ...All biohazardous waste except needles and sharps, will be single bagged prior to disposal ...p.3. ...any materials in contact with either blood or bloody drainage shall be single-bagged ...Dispose of all biohazardous wastes in plastic bags located in designated covered waste containers with foot pedals."


During Exit Interview on 03/16/17 at 12:45 p.m. these infection control issues were discussed. Nothing further was submitted for review.

Based on record review, Medical Bylaws review, and staff interview, the hospital failed to ensure that orders were countersigned by the physician within 24 hours for Patients #7, #8, #9, #10, and #21, five (5) of 24 patients reviewed.


Findings Include:


Review of record for Patients #7, #8, #9, #10, and #21 revealed multiple telephone and verbal orders taken by the nursing staff that had not been countersigned by the physician.


During an interview on 03/15/17 at 2:20 p.m. the Medical Records Director stated that telephone and verbal orders should be signed by the physician within 24 hours of the order being received.


Review of Medical Staff Bylaws (approved 8/24/09) revealed: "Medical Record ...Orders dictated over the telephone shall be signed by the person to whom they were dictated, with name of the physician per his own named. Within 24 hours, the attending physician shall sign these orders.


During Exit Interview on 03/16/17 at 12:45 p.m. these findings were discussed. Nothing further was submitted for review.

Based on record review, staff interview, and policy review, the hospital failed to provide a discharge summary for Patient #8, one (1) of 24 records reviewed, and a pertinent medical history for Patient #7, #8, #9, and #21, four (4) of 24 parients reviewed.


Findings Include:


Record review revealed Patient #8 had no documented evidence of a discharge summary.


Record review revealed Patient #7, #8, #9, and #21 had no past, social, or family history documented on the history and physical.


During an interview on 03/16/17 at 10:00 a.m. the Medical Records Director stated, "That medical record (Patient #8) is one of our incomplete records due to the discharge summary not being completed." The Medical Records Director also confirmed there were no past, social, or family histories documented on Patient #7, #8, #9, and #21's history and physicals.


Review of the facility's "Health Information Management" policy revealed, "Medical Record Content: all medical records should contain the following:..3. Complete history and Physical examination ...9. Discharge summary ...History and Physical: a history and physical is required for all patients within 24 hours of registration or admission .....A history and physical must contain the following: the patient history 1. identifying information 2. Chief concern 3. History of present illness 4. past medical history 5. family history 6. Social history 7. Review of systems ..."



During Exit Interview on 03/16/17 at 12:45 p.m. these issues were discussed. Nothing further was submitted for review.

Based on record review and staff interview, the hospital failed to ensure dated signatures on nursing notes for two (2) of two (2) wound care charts reviewed, Patients #5 and #6.


Findings Include:


Review of Patient #5 and Patient #6's wound care charts revealed no dated signatures on the Nursing Notes.

During an interview on 03/16/17 at 11:00 a.m. the Medical Records Director stated, "I have talked with our computer technologist about the wound care nurses not being able to sign and date their nursing notes and we are talking with our electronic medical records company regarding the problem."

No policy was submitted by the facility regarding this issue.


During Exit Interview on 03/16/17 at 12:45 p.m. these issues were discussed. Nothing further was submitted for review.

Based on Tissue Donation Report review, record review, staff interview, Organ and Tissue Donation Agreement, and policy review, the hospital failed to ensure its organ procurement responsibilities are met.


Findings Include:


Review of the facility's Tissue Donation Report revealed the facility had a referral compliance rate of 85% in August 2016.


Record review revealed no documentation of MORA being notified of a patient's death.


During an interview on 03/16/17 at 10:45 a.m. the Director of Nurses stated, "MORA was not notified in the one hour time frame. The nurse forgot to call."


Review of the Organ and Tissue Donation agreement revealed: "...Responsibilities of___Hospital... 7. Timely referral of all expired patients, within one hour of cardiac death, to the MORA referral line. MORA shall then be responsible for the evaluation of the patient as a potential tissue donor."


Review of the hospital's "MORA" policy (reviewed 1/2015) revealed: "Policy: It is the policy of hospital to comply with the regulations and guidelines of the Mississippi Organ Recovery Agency (MORA) ...Procedure a. Notify MORA within 30 minutes after the patient is pronounced ...d. Nursing staff should document in the patient chart: the time that MORA was notified and obtain a confirmation number."



During Exit Interview on 03/16/17 at 12:45 p.m. these issues were discussed. Nothing further was submitted for review.