HospitalInspections.org

Based on review of CAH humidity logs, AORN guidelines, and staff interview, it was determined the facility failed to provide a safe physical environment in patient care areas during surgery. This resulted in 2 months of humidity readings less than 20% in 2 of 3 operating rooms and had the potential for adverse patient outcomes. Findings include:

AORN "Guidelines for perioperative practice," 2021, stated, "The relative humidity in a restricted area [operating room] should be maintained within a range of 20% to 60%." These guidelines were not followed.

Humidity logs for 3 of 3 facility operating rooms were requested for the months of March 2021 and April 2021. The logs provided stated, "Humidity must be between 20% and 60%." The log results for humidity <20% are as follows:

March 2021:

OR 1 - 1 out of 19 surgical days had humidity <20%.
OR 2 - 4 out of 19 surgical days had humidity <20%.

April 2021:

OR 1 - 1 out of 17 surgical days had humidity <20%.
OR 2 - 4 out of 17 surgical days had humidity <20%.

For the above recorded low humidities there was no documentation if any adjustments were made to the HVAC system to increase humidity.

The Lead Scrub Tech was interviewed on 5/05/21, beginning at 4:10 PM with the Director of Quality present. She reported it was her duty to monitor and record temperature and humidity logs for the OR suites. She stated that if an OR suite was out of parameter for temperature or humidity, that OR would not be used until maintenance could bring the room into the correct parameters. She confirmed there was no documentation that the OR suites were brought into compliance prior to a surgery being done.

The CAH failed to provide a documented safe physical environment for patients receiving surgical services.

Based on observation, policy review, and staff interview, it was determined the CAH failed to document supervision of ancillary personnel by professional staff. This had the potential for missed opportunities to evaluate patient care. Findings include:

A CAH policy, "Nursing Delegation," reviewed 7/10/20, described the manner by which tasks could be delegated to UAP by nursing staff. However, the policy did not address the documented oversight of ancillary personnel. It could not be determined how professional staff documented oversight of ancillary personnel.

A tour of the ED was conducted in the presence of the Director of Quality on 5/05/21, beginning at 9:49 AM. During the tour a CNA working in the ED was interviewed. When asked what tasks she performed, she stated many different patient care tasks from taking vital signs to performing basic, delegated wound care. When asked if she documented what tasks she performed, the CNA stated, "sometimes".

During the tour an ED RN was interviewed. When asked if she documented oversight of care rendered by a CNA, the ED RN stated she was unsure. The Director of Quality stated the CAH's EMR system had the ability for professional staff to document oversight of LPN tasks, but she was unaware of the requirement of ancillary personnel oversight. The Director of Quality stated CAH professional staff were not currently documenting to that requirement.

The CAH failed to document supervision of ancillary personnel by professional staff.

Based on observation, policy review, and staff interview, it was determined the CAH failed to ensure healthcare services were provided in accordance with appropriately written policies. This directly affected 1 of 3 patients (Patient #15) whose COVID-19 screening was observed and 2 of 39 patients (#2 and #15) whose advanced directives were reviewed. This resulted in services not being furnished in a manner consistent with policies, and had the potential for avoidable, adverse patient outcomes. Findings include:

CAH policies were not followed. Examples include:

1. A CAH policy, "Language Assistance Plan", reviewed 12/2/19, stated, "...A telephone interpreter service line is available at all times to be used when a trained staff interpreter is not available in-house." This policy was not followed.

A tour of the CAH's offsite Outpatient Rehab Facility was conducted in the presence of the Director of Quality on 5/05/21, beginning at 9:00 AM. During the tour, 3 individuals were observed being screened for COVID-19 by a receptionist. One of the 3 individuals, and his wife who accompanied him, did not speak English. The individual was unable to appropriately answer the COVID-19 screening questions due to this language barrier and there was no staff present to translate. When the receptionist was advised to call the "Language Assistance Line", she stated she was unaware of this service and policy.

Language translation services were not provided in accordance with appropriate written policy.


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2. A CAH policy, "Advanced Directives", reviewed 4/03/2017, stated, "Notes in the electronic health record the presence of an advance directive." This policy was not followed.

a. Patient #15 was a 49 year old male who was admitted to the CAH on 2/12/21, with a primary diagnosis of anemia, cerebral palsy, and herpes zoster. He was admitted to a skilled swing bed on 2/17/21.

Patient #15 had a full-code order status, dated 2/12/21, signed by the admitting physician. Patient #15 completed a "Bill of Rights" form upon his admit to swing bed status on 2/17/21. Under "Cardiopulmonary Resuscitation," Patient #13 had circled and initialed, "NO I DO NOT WANT CPR." Patient #15's code status was not updated with this new directive after being admitted to swing-bed status.

The Director of Quality was interviewed on 5/06/21, beginning at 8:30 AM, and Patient #15's medical record was reviewed in her presence. She confirmed Patient #15's medical record was not updated to reflect the new advanced directive after the patient was admitted to swing bed status.

Patient #15's advanced directive was not updated.

b. Patient #2 was a 76 year old male who was admitted to the CAH on 2/22/21, with a primary diagnosis COVID-19.

Patient #2 did not have an advance directive documented in his medical record.

The Director of Quality was interviewed on 5/06/21, beginning at 8:30 AM, and Patient #2's medical record was reviewed in her presence. She confirmed Patient #2's medical record did not document an advanced directive.

Patient #2's advanced directive was not documented.

Based on CAH policy review, quality document review, and staff interview, it was determined the CAH failed to ensure policies were developed for the implementation of code blue drills and malignant hyperthermia drills. This had the potential for increased risk of patient adverse events. Findings include:

Code blue and malignant hyperthermia policies which governed the expectation, frequency, and staff responsibility concerning drills was requested from the Director of Quality on 5/05/21, and the following was provided:

- A CAH policy, "Cardiac Arrest," reviewed 9/05/19

- A CAH policy, "Malignant Hyperthermia," approved 9/12/17

A quality document, "OR Plan of Action," dated 2/14/17, stated, "Come up with fire drills and code drills and documentation records."

The Director of Quality was interviewed on 5/06/21, beginning at 8:50 AM, and the policies and quality document were reviewed in her presence. She stated the CAH did not have a policy for performing code blue and malignant hyperthermia drills. The Director of Quality stated the lack of policies had been noted during a previous survey in 2017 and that is when they created the "OR Plan of Action" document. She confirmed the plan of action had not been implemented for code blue or malignant hyperthermia drills. The Director of Quality stated the last known malignant hyperthermia drill was not documented and she did not recall when it had taken place. Additionally, she stated the last documented code blue drill was in 2017; almost 4 years prior to survey. The Director of Quality confirmed continued non-compliance with code blue drills.

The CAH failed to develop emergency policies for code blue and malignant hyperthermia drills.

Based on medical record review, job description review, and staff interview, it was determined the CAH failed to ensure documented oversight of care rendered by LPN staff by a registered nurse for 3 of 5 patients (#4, #15, and #21) who had an assigned LPN, and whose records were reviewed. This had the potential for missed opportunities to evaluate patient care.

A CAH RN job description stated, "...to include collaborating and co-signing on LPN assessments and care plans..." This job description was not followed. Examples include:

1. Patient #4 was an 82 year old female who was admitted to the CAH on 5/02/21, with a primary diagnosis of a fall with injury.

Patient #4's medical record included a "Nursing Assessment," dated 5/03/21, signed by an LPN. The assessment performed by the LPN was not co-signed by Patient #4's RN. It could not be determined if Patient #4's RN evaluated the assessment performed by the LPN.

The Director of Quality was interviewed on 5/05/21, beginning at 11:37 AM, and Patient #4's medical record was reviewed in her presence. She confirmed Patient #4's RN did not co-sign the nursing assessment performed by the LPN.

Patient #4's LPN assessment was not co-signed by her RN.

2. Patient #21 was a 38 year old male who presented to the ED on 3/22/21, with a chief complaint of seizures.

Patient #21's medical record included a "Nursing Assessment," dated 3/22/21, signed by an LPN. The assessment performed by the LPN was not co-signed by Patient 21's RN. It could not be determined if Patient #21's RN evaluated the assessment performed by the LPN.

The Director of Quality was interviewed on 5/05/21, beginning at 12:02 PM, and Patient #21's medical record was reviewed in her presence. She confirmed Patient #21's RN did not co-sign the nursing assessment performed by the LPN.

Patient #21's LPN assessment was not co-signed by her RN.



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3. Patient #15 was a 49 year old male admitted on 2/12/21 for pneumonia.

Patient #15's medical record included a "Nursing Assessment", dated 2/16/21, signed by an LPN. There was no documentation that the LPN's nursing assessment was co-signed by an RN.

The Director of Quality was interviewed on 5/06/21, beginning at 8:30 AM, and Patient #15's medical record was reviewed in her presence. She confirmed Patient #15's RN did not co-sign the nursing assessment performed by the LPN.

Patient #15's LPN assessment was not co-signed by his RN.

Based on medical record review and staff interview, it was determined the CAH failed to ensure informed consents were executed properly for 13 of 39 patients (#1, #2, #6, #7, #10, #11, #13, #15, #17, #26, #34, #36, and #37), whose records were reviewed. These incomplete consents included initial treatment informed consents, anesthesia consents, and blood transfusion consents. This had the potential for misunderstanding of the course of patient care and the ability for patients and their representatives to exercise their patient rights. Examples include:

1. Patient #1 was an 88 year old female admitted to the CAH on 3/19/21 with a primary diagnosis of acute pneumonia.

Patient #1's medical record included a"CONDITIONS OF ADMISSION" form, dated 3/19/21, signed by her. The form was not dated by the patient. The form included 3 checkboxes which indicated Patient #1 received her patient Medicaid notification, rights and responsibilities, and notification of consent to photographs/videos. These 3 checkboxes were blank. It could not be determined if Patient #1 consented to receipt of this information.

The DON was interviewed on 5/05/21 beginning at 10:50 AM, and Patient #1's medical record was reviewed in her presence. She confirmed Patient #1's consent was incomplete.

Patient #1's consent was not properly executed.

2. Patient #7 was a 79 year old female admitted to the CAH on 1/17/21 with a diagnosis of COVID-19 and shortness of breath. The patient required a blood transfusion on 1/19/21.

a. Patient #7's medical record included a "CONDITIONS OF ADMISSION" form, dated 1/17/21, signed by her. The form was not dated by patient #7.

b. Patient #7's medical record included a "CONSENT TO BLOOD TRANSFUSION" form, dated 1/19/21, signed by her. The form was not dated by patient #7.

The DON was interviewed on 5/05/21 beginning at 10:50 AM, and Patient #7's medical record was reviewed in her presence. She confirmed Patient #7's "CONDITIONS OF ADMISSION" and "CONSENT TO BLOOD TRANSFUSION" forms were both incomplete.

Patient #7's consents were not properly executed.

3. Patient #10 was a 66 year old male admitted on 3/16/21 with a primary diagnosis of chronic renal failure.

Patient #10's medical record included a"CONDITIONS OF ADMISSION" form signed by him. The form was not dated by patient #10.

The DON was interviewed on 5/05/21 beginning at 10:50 AM, and Patient #10's medical record was reviewed in her presence. She confirmed Patient #10's "CONDITIONS OF ADMISSION" form was incomplete.

Patient #10's consent was not properly executed.

4. Patient #17 was a 48 year old male admitted on 2/19/21 as a hospice respite patient.

Patient #17's medical record included a "CONDITIONS OF ADMISSION" form signed by him. The form included 3 checkboxes which indicated Patient #17 received his patient Medicaid notification, rights and responsibilities, and notification of consent to photographs/videos. These 3 checkboxes were blank. It could not be determined if Patient #17 consented to receipt of this information.

The DON was interviewed on 5/05/21 beginning at 10:50 AM, and Patient #17's medical record was reviewed in her presence. She confirmed Patient #17's "CONDITIONS OF ADMISSION" form was incomplete.

Patient #17's consent was not properly executed.

5. Patient #11 was a 39 year old female admitted on 11/2/20 with a diagnosis of induction of labor and COVID-19.

Patient #11's medical record included a "CONSENT FOR ANESTHESIA SERVICES", it was signed by the patient but not dated or timed by the patient.

The DON was interviewed on 5/05/21 beginning at 10:50 AM, and Patient #11's medical record was reviewed in her presence. She confirmed Patient #11's "CONDITIONS FOR ANESTHESIA SERVICES" was incomplete.

Patient #11's anesthesia consent was not properly executed.



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6. Patients receiving a midline catheter were not given written informed consent. An example includes:

Patient #2 was a 76 year old male who was admitted to the CAH on 2/22/21, with a primary diagnosis COVID-19.

Patient #2's medical record included a narrative "Procedure Notes," dated 3/10/21, which stated, "This is a 76-year-old male patient admitted to the emergency room in which is was requested that the patient receive a midline catheter placement secondary to the patient's diagnosis of COVID-19. PROCEDURE IN DETAIL: After informed consent, the GE ultrasound..."

There was no documentation in Patient #2's medical record he signed a consent for the midline catheter procedure

The Director of Quality was interviewed on 5/06/21, beginning at 8:30 AM, and Patient #2's medical record was reviewed in her presence. She confirmed Patient #2's medical record did not include a midline catheter placement informed consent. The Director of Quality stated that the CAH did not have a written consent form for that specific procedure.

Patient #2's midline catheter placement informed consent was not properly executed.

7. Patient #13 was an 62 year old female admitted to the CAH on 2/07/21 with a presenting diagnosis hypertensive emergency.

Patient #13's medical record included a "CONDITIONS OF ADMISSION" form, signed by her husband. The form was not dated by her husband, nor was there a witness signature or date. The form included 3 checkboxes which indicated Patient #13 received her patient Medicaid notification, rights and responsibilities, and notification of consent to photographs/videos. These 3 checkboxes were blank. It could not be determined if Patient #13 consented to receipt of this information.

The Director of Quality was interviewed on 5/05/21 beginning at 1:35 PM, and Patient #13's medical record was reviewed in her presence. She confirmed Patient #13's consent was not properly executed.

Patient #13's consent was not properly executed.

8. Patient #15 was a 49 year old male who was admitted to the CAH on 2/12/21, with a primary diagnosis of anemia, cerebral palsy, and herpes zoster.

Patient #15's medical record included a "CONDITIONS OF ADMISSION" form, signed by his caregiver. The form was not dated by his caregiver. The form included 3 checkboxes which indicated Patient #15 received his patient Medicaid notification, rights and responsibilities, and notification of consent to photographs/videos. These 3 checkboxes were blank. It could not be determined if Patient #15 consented to receipt of this information.

The Director of Quality was interviewed on 5/05/21 beginning at 1:35 PM, and Patient #13's medical record was reviewed in her presence. She confirmed Patient #15's consent was incomplete.

Patient #15's consent was not properly executed.

9. Patient #26 was a 48 year old female who was admitted to the CAH on 11/15/20, with a presenting diagnosis of possible preeclampsia.

Patient #26's medical record included a "CONDITIONS OF ADMISSION" form, signed by her. The form was not dated by her. The form included 3 checkboxes which indicated Patient #26 received her patient Medicaid notification, rights and responsibilities, and notification of consent to photographs/videos. These 3 checkboxes were blank. It could not be determined if Patient #26 consented to receipt of this information.

The Director of Quality was interviewed on 5/05/21 beginning at 1:35 PM, and Patient #26's medical record was reviewed in her presence. She confirmed Patient #26's consent was incomplete.

Patient #26's consent was not properly executed.



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10. Patient #6 was a 25 year old female who presented to the ED on 11/06/20, with a chief complaint of pregnancy related complications.

Patient #6's medical record included a "CONDITIONS OF ADMISSION TO FRANKLIN COUNTY MEDICAL CENTER" form, dated 11/06/20, signed by her. The form included a section for the time the consent was signed by Patient #6, however, this section was left blank.

The Director of Quality was interviewed on 5/05/21, beginning at 11:51 AM, and Patient #6's medical record was reviewed in her presence. She confirmed Patient #6's consent was not properly executed.

Patient #6's consent was not properly executed.

11. Patient #34 was a 24 year old female who presented to the ED on 12/13/21, with a chief complaint of pregnancy related complications.

Patient #34's medical record included a "CONDITIONS OF ADMISSION TO FRANKLIN COUNTY MEDICAL CENTER" form, dated 12/13/21, signed by her. The form included 3 checkboxes which indicated Patient #34 received her patient Medicaid notification, rights and responsibilities, and notification of consent to photographs/videos. These 3 checkboxes were blank. It could not be determined if Patient #34 consented to receipt of this information.

The Director of Quality was interviewed on 5/05/21, beginning at 10:47 AM, and Patient #34's medical record was reviewed in her presence. She confirmed Patient #34's consent was not properly executed.

Patient #34's consent was not properly executed.

12. Patient #37 was a 61 year old male who presented to the ED on 7/01/20, with a chief complaint of SOB.

Patient #37's medical record included a "CONDITIONS OF ADMISSION TO FRANKLIN COUNTY MEDICAL CENTER" form, dated 7/01/20, signed by him. The form included 3 checkboxes which indicated Patient #37 received his patient Medicaid notification, rights and responsibilities, and notification of consent to photographs/videos. These 3 checkboxes were blank. It could not be determined if Patient #37 consented to receipt of this information.

The Director of Quality was interviewed on 5/05/21, beginning at 11:31 AM, and Patient #37's medical record was reviewed in her presence. She confirmed Patient #37's consent was not properly executed.

Patient #37's consent was not properly executed.

13. Patient #36 was an 82 year old female who presented to the ED on 8/26/20, with an undocumented chief complaint.

Patient #36's medical record included a "CONDITIONS OF ADMISSION TO FRANKLIN COUNTY MEDICAL CENTER" form, dated 8/26/20, signed by her. The form included a section for the time the consent was signed by Patient #36, however, this section was left blank.

The Director of Quality was interviewed on 5/05/21, beginning at 10:54 AM, and Patient #36's medical record was reviewed in her presence. She confirmed Patient #36's consent was not properly executed.

Patient #36's consent was not properly executed.

Based on medical record review and staff interview, it was determined the CAH failed to ensure physician verbal orders were dated for 5 of 39 patients (#3, #4, #20, #21, and #37), whose records were reviewed. This resulted in a lack of clarity regarding authentication of medical record entries. Findings include:

1. Patient #20 was a 49 year old female admitted to the CAH on 3/5/21, with a presenting diagnoses of accidental drug overdose.

Patient #20's medical record included a "Medication Order" which included 9 verbal medication orders by her admitting physician. These 9 verbal medication orders were not signed by her admitting physician.

Patient #20's verbal orders were not signed by her physician.

The Director of Quality was interviewed on 5/05/21, beginning at 1:35 PM, and Patient #20's medical record was reviewed in her presence. She confirmed Patient #20's medical record included medication orders that had not been signed by her physician.

The CAH failed to ensure Patient #20's medical record entries were authenticated by appropriate staff.

2. Patient #3 was an 80 year old female admitted to the CAH on 12/01/21, with a primary diagnoses of anemia and rectal hemorrhage.

Patient #3's medical record included an order for, "diazepam oral 10 mg every day at bedtime PRN: insomnia." This order dated 12/1/21 was noted to be "Not Verified."

The Director of Quality was interviewed on 5/05/21, beginning at 1:35 PM, and Patient #3's medical record was reviewed in her presence. She confirmed Patient #3's medical record included a medication order that had not been authenticated by the physician

The CAH failed to ensure Patient #3's medical record entries were authenticated by appropriate staff.



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3. Patient #4 was an 82 year old female who was admitted on 5/02/21, with a primary diagnosis of a fall with injury.

Patient #4's medical record included a medication verbal order for Heparin IV. The verbal medication order was listed as "Not verified" as it was not dated and signed-off by her ordering physician.

The Director of Quality was interviewed on 5/05/21, beginning at 11:37 AM, and Patient #4's medical record was reviewed in her presence. She confirmed Patient #4's verbal order was not dated by her physician.

Patient #4's verbal medication order was not dated by her physician.

4. Patient #21 was a 38 year old male who presented to the ED on 3/22/21, with a chief complaint of seizures.

Patient #21's medical record included medication verbal orders for Octreotide IV and Morphine IV. The verbal medication orders were listed as "Not verified" as they were not dated and signed-off by his ordering physician.

The Director of Quality was interviewed on 5/05/21, beginning at 12:02 PM, and Patient #21's medical record was reviewed in her presence. She confirmed Patient #21's verbal orders were not dated by his physician.

Patient #21's verbal medication orders were not dated by his physician.

5. Patient #37 was a 61 year old male who presented to the ED on 7/01/20, with a chief complaint of SOB.

Patient #37's medical record included medication verbal orders for Aspirin and Furosemide IV. The verbal medication orders were listed as "Not verified" as they were not dated and signed-off by his ordering physician.

The Director of Quality was interviewed on 5/05/21, beginning at 11:31 AM, and Patient #37's medical record was reviewed in her presence. She confirmed Patient #37's verbal orders were not dated by his physician.

Patient #37's verbal medication orders were not dated by his physician.

Based on observation and staff interview, it was determined the CAH failed to ensure medical records were safeguarded against destruction by fire or water damage for one offsite medical record storage area observed. This had the potential for irretrievable medical records. Findings include:

A tour of the offsite medical records storage area for the CAH was conducted on 5/04/21, beginning at 8:30 AM, in the presence of the Director of Quality and the Maintenance Director. The medical records were stored in cardboard file boxes. No sprinklers were observed. The Maintenance Director stated that the building did not have a fire suppression system. There were no countermeasures in place to protect the medical records from fire or water damage.

The Director of Quality and the Maintenance Director were interviewed on 5/04/21, during the tour. When asked if the medical records in the offsite storage area were original, non-archived documents, the Director of Quality stated yes. The Director of Quality confirmed the medical records in the offsite storage area were not safeguarded against destruction by fire or water damage.

The CAH failed to ensure original, non-archived patient medical records were safeguarded against destruction by fire or water.

Based on observation, policy review, CDC and AORN guidelines review, and staff interview, it was determined the CAH failed to ensure clinical staff followed effective infection control practices of hand hygiene. This had the potential to impact all patients receiving services at the facility and placed patients at an increased risk for infections. Findings include:

The CDC website, "When and How to Wash Your Hands," accessed on 5/12/21, stated, "To prevent the spread of germs during the COVID-19 pandemic, you should also wash your hands with soap and water for at least 20 seconds or use a hand sanitizer with at least 60% alcohol to clean hands BEFORE and AFTER:

"Touching your eyes, nose, or mouth
Touching your mask
Entering and leaving a public place
Touching an item or surface that may be frequently touched by other people, such as door handles..."

AORN "Guidelines for perioperative practice," 2021, stated to perform hand hygiene:

Before and after patient contact
After contact with patient surroundings, including inanimate surfaces and objects including medical equipment, in the immediate vicinity of the patient
Assessing an invasive device...
Administering or preparing medications...
Administering regional anesthesia
Performing airway manipulation"

These guidelines were not followed. Examples include:

Patient #38 was a 75 year old female who was admitted on 5/05/21, for a scheduled gall bladder surgery.

Patient #38's surgery was observed on 5/05/21, beginning at 9:26 AM, with the IC nurse present. The following breaches in infection prevention were observed during the surgery:

a. The CRNA did not perform hand hygiene during the surgery while performing his duties. The CRNA was observed to touch the patient, equipment, patient surroundings, medical equipment, administered medications, and touched his mask throughout the surgery. These tasks were performed without hand hygiene.

The CRNA was interviewed after the surgery, beginning at 10:57 AM. He confirmed he had not performed hand hygiene during the Patient #38's surgery or after touching the above items and stated, "I probably should."

b. The Director of Surgical Services exited the OR 3 times during Patient #38's surgery to access the supply room and did not perform hand hygiene prior to entering the OR again.

The IC nurse was interviewed after the surgery, beginning at 11:05 AM. The IC nurse stated the CAH followed CDC and AORN infection control guidelines. She confirmed the CRNA and Director of Surgical Services had not followed CDC and AORN hand hygiene protocol.

The CAH did not follow nationally recognized guidelines regarding proper hand hygiene.