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Based on a review of the facility policies and procedures, review of Medical Staff Minutes and an interview with facility staff it was determined the Governing Body failed to:

a) Ensure there was an established Infection Control Plan with policies and procedures in place for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel

b) Ensure there were established policies and procedures for patients receiving Physical Therapy, Occupational Therapy and Speech Language Pathology Services.

This had the potential to affect all patients in the facility.

Refer to A 048

Based on a review of the facility policies and procedures, review of Medical Staff Minutes and interview with facility staff it was determined the facility failed to:

a) Ensure a qualified Infection Control Director was appointed as Director of the Infection Control Committee

b) Establish infection control policies and procedures to ensure a system was in place for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel

c) Maintain a log of incidents related to infections and communicable diseases

d) Ensure the Infection Control program was reviewed for concerns and interventions put in place

e) Establish policies and procedures for patients receiving Physical Therapy, Occupational and Speech Language Pathology Services.

This had the potential to affect all facility patients.

Findings Include:

Centers for Disease Control and Prevention (CDC) has defined "infection control professional" as a person whose primary training is in either nursing, medical technology, microbiology, or epidemiology and who has acquired specialized training in infection control.

1. Infection Control:

During an interview on 5/3/12 at 11:30 AM, with Employee Identifier (EI) # 2, Quality Director, EI # 3, Director of Nursing, and EI # 4, Assistant Director of Nursing, revealed EI # 2, EI # 3, and EI # 4 were the Infection Control Committee. The surveyor asked what the Infection Control committee qualifications were and no documentation was supplied to show the committee had acquired specialized training in infection control.

During an interview on 5/3/12 at 11:30 AM, EI # 2, Quality Director, EI # 3, Director of Nursing and EI # 4, Assistant Director of Nursing were asked for policies and procedures for Infection Control, EI # 2 stated there were no policies and procedures for the Infection Control Committee to follow for reporting, investigating, and controlling infections in the facility.

During an interview on 5/3/12 at 11:35 AM, with EI # 2, Quality Director, EI # 3, Director of Nursing and EI # 4, Assistant Director of Nursing, they confirmed there was no documentation of a log which identified incidents of infection and communicable disease throughout the hospital and documented infections and communicable diseases in patients and staff (patient care staff and non-patient care staff, including employees, contract staff and volunteers).

During a review of the Medical Staff Minutes on 5/3/12 at 8:15 AM, there was no documentation of a review of the Infection Control Program on the May 2011, November 2011, January 2012, February 2012, March 2012, and April 2012 documents. These Medical Staff Minutes also did not include a discussion of the infection control as part of the quality assurance program.

There was no documentation provided to the surveyors of the chief executive officer, medical staff or the director of nursing services reviewing the infection control program.

During an interview on 5/3/12 at 11:35 AM, with EI # 2, Quality Director, EI # 3, Director of Nursing and EI # 4, Assistant Director of Nursing when asked if there was a report about tracking and trending infections in their facility, EI # 2, EI # 3, and EI # 4 verified there was no documentation of tracking or tending of infections.

2. Physical Therapy, Occupational Therapy and Speech Language Pathology:

During a tour of the Outpatient Therapy Department on 5/2/12 at 1:50 PM, with EI, # 6, Therapy Director and EI # 3, the Director of Nursing, the surveyor requested the Therapy department's policies and procedures. EI # 6 stated, "We don't have any that I am aware of. I think the old company took our policies with them when they left."

An interview conducted on 5/3/12 at 11:00 PM with EI # 1, the Administrator, confirmed that there were no therapy policies and procedures.

Based on a review of the hospital's written inpatient rights, medical records and interview with facility administrative staff, it was determined the facility did not provide the contact number for the patients or to patients' representatives to voice grievances nor did the facility make available to patients or to patients' representatives the State agency phone number for filing a grievance. This affected 17 of 17 inpatient medical records reviewed and had the potential to affect all patients within the hospital.

The findings include:

Review of 17 of 17 inpatient medical records revealed there was no documentation the patients or their representatives were informed of the hospital contact person or the telephone number to voice a grievance verbally or in written form to the hospital, nor was there documentation the patients or their representatives received information on how to lodge a complaint with the State agency.

Review of the hospital's "Patient Bill of Rights" revealed there was no documentation on how to lodge a complaint with the State agency or who to contact at the hospital.

An interview was conducted on 5/3/11 at 12:15 PM, with Employee Identifier (EI) # 3, the Director of Nurses, who verified the document "Your Rights as a Hospital Patient" did not contain the hospital contact number or the State Hotline number.

Based on record review, policy review, and interview with facility staff, the hospital failed to obtain consent for treatment in 4 of 20 Emergency Room (ER) records reviewed. This affected ER record # 10, 12, 14 and 16.

Findings include:

Policy:
Subject: Informed Consent

1. Objective
To properly obtain written permission for miscellaneous treatments and/or procedures. ...
... E. Obtain patient signature. ...

1. ER # 10 with a date of service (DOS) 12/30/11 did not contain a signed consent for treatment.

2. ER # 12 with a DOS 2/7/12 did not contain a signed consent for treatment.

3. ER # 14 with a DOS 11/15/11 did not contain a signed consent for treatment.

4. ER # 16 with a DOS 11/3/11 did not contain a signed consent for treatment.

An interview conducted on 5/3/12 at 12:35 PM, with Employee Identifier # 3, the Director of Nursing, confirmed there were no consent forms on the aforementioned records.

Based on review of medical records (MR), review of policies and procedures, review of the Alabama Board of Nursing Administrative Code, review of the facility Job Descriptions for Charge Nurse and Licensed Practical Nurse (LPN) and staff interview, it was determined the hospital failed to:

1. Ensure a registered nurse (RN) performed a comprehensive assessment

2. Ensure a Registered Nurse (RN) was assigned to document an assessment on all inpatients of the hospital. This affected MR # 26, 1 of 17 MRs reviewed and had the potential to affect all inpatients.

3. Ensure the Registered Nurse administered blood in 1 of 3 patients requiring blood administration. This affected MR # 28 and had the potential to affect all patients requiring blood administration.

Findings Include:

Refer to A 395, A 397 and A 409.

Based on review of medical records (MR), review of the Alabama Board of Nursing Administrative Code, review of the facility Job Descriptions for Charge Nurse and Licensed Practical Nurse (LPN) and staff interview, it was determined the hospital failed to ensure a registered nurse (RN) performed a comprehensive assessment for 1 of 17 MRs reviewed. This practice delegated to the LPN the responsibility of completing patient assessments. This affected 1 (MR # 26) of 17 inpatient MRs reviewed and had the potential to affect all patients who were admitted to the hospital.

The findings include:

Alabama Board of Nursing
Administrative Code

610-X-6-.01 Definitions

(2) Assessment, Comprehensive: the systematic collection and analysis of data including the physical, psychological, social, cultural and spiritual aspects of the patient by the registered nurse for the purpose of judging a patient's health and illness status and actual or potential health needs. Comprehensive assessment includes patient history, physical examination, analysis of the data collected, development of the patient plan of care, implementation and evaluation of the plan of care.

(3) Assessment, Focused: An appraisal of a patient's status and specific complaint through observation and collection of objective and subjective data by the registered nurse or licensed practical nurse. Focused assessment involves identification of normal and abnormal findings, anticipation and recognition of changes or potential changes in patients.

610-X-6-.04 Practice of Professional Nursing (Registered Nurse Practice)

(1) The practice of professional nursing includes, but is not limited to:

(e) Conducting and documenting comprehensive assessments and evaluations of patients and focused nursing assessments patient's health status, and may contribute to a comprehensive assessment performed by the registered nurse ...

610-X-6-.05 Practice of Practical Nursing (Licensed Practical Nurse Practice)

(1) The practice of practical nursing includes, but is not limited to:
(d) Conducting and documenting focused nursing assessments of the health status of patients.

610-X-6-.09 Assessment Standards
(1) Patient assessment shall be provided in accordance with the definitions of professional nursing and practical nursing as defined in the Alabama Nurse Practice Act, Section 34-21-1.
(2) The registered nurse shall conduct and document comprehensive and focused nursing assessments of the health status of patients

The facility "Job Description: Charge Nurse" was reviewed and it documented, "Duties and Responsibilities: Supervise nursing activities of his/her nursing station on each shift; ... make rounds to observe and evaluate physical, emotional, and social needs of patients ... The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established hospital policies and procedures ... Job Knowledge: Nursing policies and procedures; ... federal, state, and local laws and regulations relating to patient care; comprehensive knowledge of nursing practices ... Functions: 1. Responsible for nursing care of patients during his/her shift."

The facility "Job Description: Hospital Licensed Practical Nurse" was reviewed and it documented, "Summary of Duties: The licensed practical nurse performs a wide variety of practical nursing duties in the care of assigned patients in accordance with established regulations and specific instructions from the professional nurses and physicians. His/ Her functions are governed by the Alabama Board of Nursing."

MR # 26 was admitted to the facility on 3/15/12 with diagnoses to include Congestive Heart Failure.

The Initial Interview for assessment was conducted by Employee Identifier (EI) # 7, a LPN, on 3/15/12 at 12:30 PM.

The Initial Physical Assessment was conducted by EI # 7, a LPN, on 3/15/12 at 2:51 PM, and EI # 8, a LPN, assessed MR # 26 at 10:38 PM. There was no documentation the RN completed the initial assessment or assessed the patient on 3/15/12.

The 3/16/12 "Patient Progress Notes" documented MR # 26 was assessed 4 times by the LPN, but there was no documentation of an assessment by a RN on 3/16/12.

The 3/17/12 "Patient Progress Notes" documented MR # 26 was assessed 1 time by a LPN and 1 time by a RN.

The 3/19/12 "Patient Progress Notes" documented MR # 26 was assessed 3 times by the LPN, but there was no documentation of an assessment by a RN on 3/19/12.

The 3/20/12 "Patient Progress Notes" documented MR # 26 was assessed 3 times by a LPN and 1 time by a RN.

The 3/21/12 "Patient Progress Notes" documented MR # 26 was assessed 1 time by a LPN and was discharged home without an assessment by an RN on 3/21/12.

MR # 26 was assessed 14 times by the LPN and 2 times by an RN during the 7 day acute inpatient stay.

During an interview on 5/3/12 at 12:55 PM, with EI # 3, Director of Nursing and EI # 4, Assistant Director of Nursing they verified the LPN assessed some patients depending on the shift census.

Based on medical record (MR) review, review of the Alabama Board of Nursing Administrative Code, review of the facility Job Description for Charge Nurse and Licensed Practical Nurse (LPN) and interview the facility failed to ensure a Registered Nurse (RN) was assigned to document a comprehensive assessment on all inpatients of the hospital. This affected MR # 26, 1 of 17 MRs reviewed and had the potential to affect all inpatients.

The findings include:

Alabama Board of Nursing
Administrative Code

610-X-6-.01 Definitions

(2) Assessment, Comprehensive: the systematic collection and analysis of data including the physical, psychological, social, cultural and spiritual aspects of the patient by the registered nurse for the purpose of judging a patient's health and illness status and actual or potential health needs. Comprehensive assessment includes patient history, physical examination, analysis of the data collected, development of the patient plan of care, implementation and evaluation of the plan of care.

(3) Assessment, Focused: An appraisal of a patient's status and specific complaint through observation and collection of objective and subjective data by the registered nurse or licensed practical nurse. Focused assessment involves identification of normal and abnormal findings, anticipation and recognition of changes or potential changes in patients.

610-X-6-.04 Practice of Professional Nursing (Registered Nurse Practice)

(1) The practice of professional nursing includes, but is not limited to:

(e) Conducting and documenting comprehensive assessments and evaluations of patients and focused nursing assessments patient's health status, and may contribute to a comprehensive assessment performed by the registered nurse ...

610-X-6-.05 Practice of Practical Nursing (Licensed Practical Nurse Practice)

(1) The practice of practical nursing includes, but is not limited to:
(d) Conducting and documenting focused nursing assessments of the health status of patients.

610-X-6-.09 Assessment Standards
(1) Patient assessment shall be provided in accordance with the definitions of professional nursing and practical nursing as defined in the Alabama Nurse Practice Act, Section 34-21-1.
(2) The registered nurse shall conduct and document comprehensive and focused nursing assessments of the health status of patients ... ...

The facility "Job Description: Charge Nurse" was reviewed and it documented, "Duties and Responsibilities: Supervise nursing activities of his/her nursing station on each shift; ... make rounds to observe and evaluate physical, emotional, and social needs of patients ... The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established hospital policies and procedures ... Job Knowledge: Nursing policies and procedures; ... federal, state, and local laws and regulations relating to patient care; comprehensive knowledge of nursing practices ... Functions: 1. Responsible for nursing care of patients during his/her shift."

The facility "Job Description: Hospital Licensed Practical Nurse" was reviewed and it documented, "Summary of Duties: The licensed practical nurse performs a wide variety of practical nursing duties in the care of assigned patients in accordance with established regulations and specific instructions from the professional nurses and physicians. His/ Her functions are governed by the Alabama Board of Nursing."

MR # 26 was admitted to the facility on 3/15/12 with diagnoses to include Congestive Heart Failure.

The Initial Interview for assessment was conducted by Employee Identifier (EI) # 7, a LPN, on 3/15/12 at 12:30 PM.

The Initial Physical Assessment was conducted by EI # 7, a LPN, on 3/15/12 at 2:51 PM, and EI # 8, a LPN, assessed MR # 26 at 10:38 PM. There was no documentation the RN completed the initial assessment or assessed the patient on 3/15/12.

The 3/16/12 "Patient Progress Notes" documented MR # 26 was assessed 4 times by the LPN but there was no documentation of an assessment by a RN on 3/16/12.

The 3/17/12 "Patient Progress Notes" documented MR # 26 was assessed 1 time by a LPN and 1 time by a RN.

The 3/19/12 "Patient Progress Notes" documented MR # 26 was assessed 3 times by the LPN but there was no documentation of an assessment by a RN on 3/19/12.

The 3/20/12 "Patient Progress Notes" documented MR # 26 was assessed 3 times by a LPN and 1 time by a RN.

The 3/21/12 "Patient Progress Notes" documented MR # 26 was assessed 1 time by a LPN and was discharged home without an assessment by an RN on 3/21/12.

MR # 26 was assessed 14 times by the LPN and 2 times by an RN during the 7 day acute inpatient stay.

During an interview on 5/3/12 at 12:55 PM, with EI # 3, Director of Nursing; and EI # 4, Assistant Director of Nursing; they verified a RN was not assigned to assess all inpatients.

Based on review of medical records and interview with facility staff, it was determined the registered nurse failed to administered blood in 1 of 3 patients requiring blood administration. This affected medical record (MR) # 28 and had the potential to affect all patients receiving blood.

1. MR # 28 was admitted to the facility on 2/11/12 with diagnoses including, Chronic Obstructive Pulmonary Disease (COPD), Pneumonia and Symptomatic Anemia.

Review of the Emergency Room (ER) record dated 2/11/12 revealed a physicians verbal order as follows:

"Order: 2/11 12:36 ... (CBC) Complete Blood Count w(with)/Differential
Actions: Order entered by ...; order entered at 2/11 13:41; specimen collected by ...; specimen collected at 2/11 15:42; completed at 2/11 15:42."

"Order: 2/11 12:36 ... Type and Screen
Actions: Order entered by ...; order entered at 2/11 13:41; specimen collected by ...; specimen collected at 2/11 15:42; completed at 2/11 15:42."

Review of the patients History and Physical dictated by the physician on 2/11/12 revealed a hemoglobin of 7.6 on admission.

Review of the admitting physician orders written on 2/11/12 and signed off by the Registered Nurse (RN) at 3:30 PM revealed: "... CBC ... in AM ...
Transfuse 2 units ... PRBCs (Packed Red Blood Cells)...."

Review of the MR revealed a CBC obtained on 2/12/12 at 6:02 AM, with results completed at 6:28 AM. The White Blood Cell Count revealed (WBC), "69.19 revf (verified) by repeat test panic value call to ... (nurse) tech/time called 6:32 AM.
Hemoglobin revealed, 6.2, revf (verified) by repeat test panic value call to ... (nurse) tech/time called 6:32 AM."

Review of the Patient Progress Note by the RN on 2/12/12 at 6:45 AM, revealed, "... (physician) notified of WBC count 69.19. No fever noted. Pt (patient) asymptomatic. There was no documentation that the physician was notified of the patient's hemoglobin panic value of 6.2.

Review of the MR revealed a Blood Consent form was signed on 2/12/12 at 7:35 AM. The patient was transferred to another facility at 11:40 AM.

The patient did not receive the 2 units of blood as ordered by the physician during the 12 hour hospital stay nor prior to being transferred.

During an interview on 5/3/12 at 8:15 AM, Employee Identifier # 3, the Director of Nursing, confirmed that the patient did not receive the blood as ordered by the physician.

Based on medical record reviews, review of facility policy and interviews with the facility staff, it was determined the medical record (MR) did not include orders, measurements or treatment documentation necessary to monitor the patient's condition in 2 of 2 patients with wounds. This affected MR #'s 26 and 27and had the potential to affect all patients with wounds.

The findings include:

Policy
Decubitus/Skin Care Assessment
"The patient must then be assessed by the receiving nurse ... All staging of decubitus/pressure areas must be done by two nurses.

The attending physician (or on- call physician) must be advised immediately of any skin changes and document such in the progress notes.

Skin assessments must be performed and documented at least twice per shift.

A weekly wound assessment sheet must be completed by the charge nurse on all patients with skin problems and at the time of discharge of a patient regardless of length of stay."

A review of the facility form "Decubitus/Skin Care Assessment" revealed the measurements of wounds are to be measured "size in centimeters and depth".

1. MR # 26 was admitted to the facility on 3/15/12 with diagnoses to include Congestive Heart Failure.

A physician order dated 3/15/12 documented "Wet to Dry dsg (dressing) to wounds BID (twice a day)." This order did not identify what wounds were to receive this wound care and did not identify the wound cleanser to be used. There was no documentation the nurse called the physician to clarify this order.

There was no wound care assessment sheets in the MR per facility policy and no additional work sheets were provided prior to the exit conference on 5/3/12.

The Initial Physical Assessment was conducted by Employee Identifier (EI) # 7, a Licensed Practical Nurse (LPN), on 3/15/12 at 2:51 PM. The section "Incisions/ Dressing" noted MR # 26 had a "dsg (dressing) to scrotal area". The section "Other Types of Wound" documented, "Coccyx area 3x3, pink tissue with yellow drainage. Approx (approximately) 1-2 inches deep. Old abcess (abscess) area. Some healing noted. No necrotic tissue." The section Nurses Notes documented: "Old drg (dressing) to scrotal area. 2 open wounds to scrotal sac. Draining pus and blood at times. Wound size ? inch in diameter noted for both puncture areas. Area to coccyx apprx (approximately) 3x3, yellow drainage noted. No drg (dressing) noted. Will consult md (medical doctor) for order ...". The nurse note did not identify the location of one scrotal wound in relation to the other scrotal wound, nor identify the wounds in centimeters (cm), and did not document exact measurements of the wounds.

The "Patient Progress Notes" for 3/15/12 at 10:38 PM, written by a LPN, EI # 8, documented, "Description of Wound: Lesion. Description of Wound: Foul odor, Drainage noted. ... Wound Status Assessment: No change from previous assessment."

EI# 8 did not identify which wound was addressed in this note. There was no documentation the wounds and the foul odor were reported to a registered nurse (RN) on admission. There was no documentation the wound care was completed on the wounds as ordered and the wounds were not documented at least twice per shift on 3/15/12 as the facility policy directed.

The "Patient Progress Notes" for 3/16/12 at 00:00 (midnight) written by a LPN, EI # 9 documented, "Dressing: Dry and intact, Wet to Dry ... Pressure Ulcer Drainage/Dressing: Wet to dry dressing ... Description of Wound: Dressing clean, dry and intact, No Drainage." There was no documentation when dressings and wound care had occurred, nor where the dressings were applied.

The "Patient Progress Notes" for 3/16/12, at 2:00 PM, written by a LPN, EI # 7, documented, "Nurse Notes: Wound care to coccyx and scrotal areas. Coccyx still with yellow drainage noted. Foul odor noted. Cleaned with NS (normal saline). Wet to Dry drg applied. ...". There was no physician order to cleanse with NS. There was no documentation the Nurse verified with the physician what type of wound cleaner to use on each wound.

The "Patient Progress Notes" for 3/16/12 at 8:13 PM, written by a LPN, EI # 8, documented, "Pressure Ulcer Drainage/Dressing: Serous, wet to dry dressing, small amount. Other Types of Wounds: Lesion. Description of wound: wet to dry. Wound drainage/ exudates: moderate, Purulent, Serous. Wounds cleansed with Normal Saline, Complex drsg (dressing) change with packing wet/dry. Dressing changed." There was no documentation the RN Charge Nurse or physician was informed of the changes of a wound related to the purulent drainage or the need for packing a wound. This note does not identify which wound was draining the moderate amount of purulent drainage or which wound needed packing with wet to dry dressing. There were no physician orders to pack a wound with a wet to dry dressing. The wounds were not documented at least twice per shift 3/16/12 as policy directed.

The "Patient Progress Notes" for 3/17/12 at 7:30 AM, written by a RN, EI # 10, documented, "Pressure Ulcer Drainage/ Dressing: Large amount, Serosanguinous." There was no wound care documented. There was no documentation the physician was notified of the changes in the amount of drainage.

The "Patient Progress Notes" for 3/17/12 at 9:44 PM, written by a LPN, EI # 11, documented, "Type of dressing: Wet to Dry ... Wound Interventions: wound cleansed with normal saline." The wounds were not documented at least twice per shift 3/17/12 as policy directed.

The "Patient Progress Notes" for 3/18/12 at 4:09 AM, written by a LPN, EI # 11, documented, "Dsg change to coccyx and scrotum done". The note did not document what type of dressing was applied or a description of the wounds.

The "Patient Progress Notes" for 3/18/12 at 7:30 AM, written by a RN, EI # 10, "Wound Interventions: Drsg (dressing) change BID, dressing clean and dry and intact." This note did not document if the wounds dressings were changed or a description of the wounds.

The "Patient Progress Notes" for 3/18/12 at 5:25 PM, written by a RN, EI # 10, "Nurse Notes: wound clean with normal saline applied 4 x 4's, to scrotum and 4 x 4's, ABD (abdominal pad) pad to buttouck (buttock) ... drsg changed." There was no physician order for the NS or the ABD pad in the medical record. There was no documentation the physician was informed of the increase in drainage.

The "Patient Progress Notes" for 3/18/12 at 8:44 PM, written by a LPN, EI # 11, documented, "General skin condition: intact ... Incisions/ Dressing: Not Applicable ... Dressing: Dry and Intact. ... Pressure Ulcer condition: N/A, Pressure Ulcer Drainage/ Dressing: N/A, Other Types of Wound: N/A." There was no documentation MR # 26 had several wounds and needed wound care during EI # 11's shift. The wounds were not documented at least twice per shift 3/18/12 as policy directed.

The "Patient Progress Notes" for 3/19/12 at 1:04 AM, written by a LPN, EI # 11, documented "Pressure Ulcer Condition: N/A, Pressure Ulcer Drainage/ Dressing: N/A ... Description of Wound: Dressing clean, dry and intact." There was no documentation the wound was assessed or dressing was changed during this shift.

The "Patient Progress Notes" for 3/19/12 at 8:00 AM, written by a LPN, EI # 7, documented "Nurses Notes: Dsg to Coccyx and scrotal area intact." A Nurse note was documented at 8:53 AM, "Wound care to Coccyx. Cleaned with NS, wet to dry drg applied. Small amt (amount) yellowish drainage noted. Odor noted. ... Scrotal dsg intact. Areas with healing noted. No necrotic tissue, pink tissue noted." There was no documentation the scrotal dressing was changed. The wounds were not documented at least twice per shift 3/19/12 as policy directed.

The "Patient Progress Notes" for 3/20/12 at Midnight, written by a LPN, EI # 9, documented the coccyx wound dressing was dry and intact but there was no documentation the scrotal wound was assessed.

The "Patient Progress Notes" for 3/20/12 at 8:00 AM, written by a LPN, EI # 7, documented MR # 26 was placed on "contact isolation ... Dsg intact to coccyx and scrotal area." The Nurse note at 10:30 AM, documented, "wound care to coccyx and scrotal area. Cleaned with NS." There was no physician order for the NS documented in the MR.

The "Patient Progress Notes" for 3/20/12 at 5:14 PM, written by a LPN, EI # 8, documented, "Description of Wound: Wound is healing, foul odor, drainage noted. Type of Dressing: Wet to Dry. Wound Drainage/Exudate: Serous, Minimum." There was no documentation which wound received the wound care.

The "Patient Progress Notes" for 3/20/12 at 10:12 PM, written by a LPN, EI # 8, documented "Drg change to scrotum area. Bloody drainage noted soaked two 4 x 4 gauze pads dsg change to coccyx area. Small amt. (amount) of serous drainage noted." There was no documentation the physician was informed of the increase in drainage or the drainage was bloody. The wounds were not documented at least twice per shift 3/20/12 as policy directed.

The "Patient Progress Notes" for 3/21/12 at 8:00 AM, a LPN, EI # 7, documented "Dsg intact to coccyx and scrotal area." The nurses note at 9:17 AM, "Wound care to coccyx and scrotum. Wet to dry dsg applied after cleaning with NS. Secured with 4 x 4s and tape. Still purulent yellowish drainage to coccyx areas. Bloody drainage noted from scrotal areas." There was no physician order for the NS documented in the MR for cleaning the wounds.

During an interview on 5/3/12 at 12:55 PM, with EI # 3, Director of Nursing and EI # 4, Assistant Director of Nursing they verified the MR did not contain the "Decubitus/Skin Care Assessment", wound care orders for each wound, wound measurements in centimeters, wound assessments twice a shift, and notification of physician of changes in wounds.

There was no documentation MR # 26's wounds were measured in "size in cm" (centimeters) and depth, to assist with determination of wound deterioration. The wound care orders were vague related to what wounds were identified to receive the wet to dry dressings and the orders were not clarified by nursing staff. There was no order for cleansing the wound with NS or any other wound cleaner and the nurse failed to clarify the order with the physician. There was no documentation the RN Charge nurse was informed about MR # 26's many concerns until the RN staff nurse took care of MR # 26 on 3/17/12 (patient was admitted on 3/15/12). The weekly wound assessment sheet was not documented as completed by the charge nurse for MR # 26 at admission nor at the time of discharge.

2. MR # 27 was admitted to the facility on 10/29/11 with diagnoses to include Infected Leg Ulcer and Cellulitus of Lower Extremity.

The 10/29/11 physician orders documented, "Local wound care". The nurse did not obtain a clarification of this order as to what types of wound care and to which wound. There was also no frequency order to determine when the dressings were to be changed.

The "Patient Progress Notes" for 10/29/11 at 5:40 PM, a RN, EI # 12, documented, " General Skin Condition: Wounds. ... Skin Condition: Ulcers. ...Incisions/ Dressing: Dry and Intact. ... Description of wound: Drainage noted. Wound Drainage/Exudate: Serosanguinous. Wound Interventions: Wound cleansed with normal saline, Dressing changed." There was no order for NS and MR # 27 had multiple wounds on his lower extremities. There was no wound assessment sheet that identified where the wounds were located, each wound size and what type of wound care was needed for each wound.

The "Patient Progress Notes" for 10/30/11 at 5:15 AM, a RN, EI # 13, documented, "Description of Wound: Dressing clean, dry and intact." There was no documentation of which of MR # 27's wounds were "clean, dry, and intact".

The "Patient Progress Notes" for 10/30/11 at 8:12 AM, a RN, EI # 12, documented, "Dressing: Dry and intact." There was no documentation of which of MR # 27's wounds were "clean, dry, and intact".

The "Patient Progress Notes" for 10/30/11 at 10:00 AM, a RN, EI # 12, documented, "Nurse Notes: ... Dressing changed per protocol." There was no documentation of which of MR # 27's wounds had a dressing change. EI# 12 documented "per protocol" there was no documentation of what type of wound care was provided.

The "Patient Progress Notes" for 10/30/11 at 7:51 PM, a RN, EI # 14, documented, "General Skin Condition: Intact. ... Other types of Wound: N/A (not applicable)." EI # 14 did not document an assessment of the multiple wounds to MR # 27 lower extremities. The wounds were not documented at least twice per shift 10/30/11 as policy directed.

A review of the 10/31/11 revealed there was no documentation of MR # 27's wound assessments and there were no assessments of the wounds to the lower extremities.

A verbal order for saline wet to dry dressing change every shift and when needed was written 11/1/11.

The "Patient Progress Notes" for 11/1/11 at 1:00 AM, a LPN, EI # 11, documented, "Description of Wound: Dressing clean, dry and Intact, No Odor, Drainage noted. Type of dressing: Wet to dry. Wound drainage/ Exudate: None noted. Moderate, Serosanguinous. Wound Interventions: Dressing changed, Wound cleansed with normal saline." The documentation did not identify which wound received a dressing change and the wound care orders did not identify which wounds needed this wet to dry dressings.

The "Patient Progress Notes" for 11/1/11 at 8:00 AM, a LPN, EI # 7, documented "Incisions/Dressings: Dry and intact ... Dsg intact to both lower ext (extremities)." The nurse note at 11:15 AM, by EI # 7, documented "Rt (right) lower leg has several areas where skin has come off. No drainage. Bleeding noted. ... Sizes ranging from nickel to quarter size. Cleansed with NS, wet to dry dsg applied. ... Left lower leg has large area under the calf. No drainage or odor. ... area approx 4x4 in size. On the shin area 2 small areas breaking. All areas cleaned with NS with wet to dry dsg applied." The nurse did not use centimeters in measuring the wounds and did not identify on a wound assessment sheet per facility policy. There was no documentation the physician was notified of the bleeding wounds. The wound care order did not clarify which wounds needed wet to dry dressings.

The "Patient Progress Notes" for 11/1/11 at 3:51 PM, a LPN, EI # 8, documented "Skin Condition: Intact ... Incisions/Dressing: Location: left lower leg." There was no documentation the other wounds on the legs were assessed or if the other wounds had dressings applied. There were no other wound assessments for the evening shift. The wounds were not documented at least twice per shift 11/1/11 as policy directed.

The "Patient Progress Notes" for 11/2/11 at 8:00 AM, a LPN, EI # 7, documented "dressing to bilateral lower ext. dry and intact. Lower ext noted swelling bilateral." There was no documentation the physician was notified of the bilateral swelling of MR # 27's lower legs. The 9:30 AM, Nurse notes documented, "Dsg change to both lower legs. No Odor, drainage noted ... Decreased swelling." There was no documentation what type of wound care was completed to each wound.

The "Patient Progress Notes" for 11/2/11 at 15:30 PM, a LPN, EI # 15, documented "Dsg (dressing) to both legs clean dry and intact with no drainage noted." There were no other wound assessments for the evening shift. The wounds were not documented at least twice per shift 11/2/11 as policy directed. There was only one dressing change documented for 11/2/11, not every shift as ordered.

The "Patient Progress Notes" for 11/3/11 at 10:30 AM, a LPN, EI # 7, documented "Patient getting ready for discharge ... Dressing change done before discharge. Dry and intact no drainage." There was no documentation what wound received wound care or a description of the wounds prior to discharge as per facility policy.

There was no documentation MR# 27's wounds were measured "size in cm (centimeters) and depth, to assist with determination of wound deterioration. The wound care orders were vague related to what wounds were identified to receive the wet to dry dressings and the orders were not clarified by nursing staff. The weekly wound assessment sheet was not documented as completed by the charge nurse for MR # 27 at admission nor at the time of discharge.

During an interview on 5/3/12 at 12:45 PM, with EI # 3, Director of Nursing and EI # 4, and the Assistant Director of Nursing they verified the nurse did not document the physician was notified of wound changes, skin assessments were not documented twice per shift as directed in policy, wounds were not measured in size in cm and depth, and the wound assessment sheet was not completed on admission, weekly, and at discharge for MR # 26 and 27.

Based on a review of the facility CLIA (Clinical Laboratory Improvement Amendments) certificate, a review of a letter sent to the facility from the Centers for Medicare & (and) Medicaid Services dated 1/24/12 and a meeting conducted by phone with state agency personal responsible for CLIA, it was determined the facility failed to ensure the laboratory (lab) services were provided under a current CLIA certificate of compliance. This had the potential to affect all patients in the facility.

Findings Include:

Letter:
Greene County Hospital
1/24/12

Department of Health & Human Services
Centers for Medicare & Medicaid...
... RE: LOSS OF ACCREDITATION FROM COLA
CLIA number: 01D0301897
... As a result of the loss of accreditation from COLA, Greene County Hospital laboratory is no longer deemed to meet the CLIA requirements. In addition, the CLIA certificate of accreditation issued to the laboratory for the period of February 23, 2011 to February 22, 2013 is longer applicable...
To facilitate the process and avoid any gap in certification, we recommend your laboratory apply for a certificate of compliance ... To apply for a certificate of compliance, please contact the State agency at: ...

During a tour of the laboratory department on 5/1/12 at 1:00 PM with Employee Identifier (EI) # 5, the Lab Manager, the surveyor requested the labs CLIA certificate. A framed CLIA certificate was taken off the wall and submitted to the surveyor. CLIA number revealed, "01D0301897 with an expiration date of 2/22/13". The Lab Manager did not reveal that the certificate was no longer applicable.

A meeting was conducted by phone on 5/7/12 at 2:00 PM, with State agency personal responsible for CLIA. The State CLIA personal reported that the facility does not have a current CLIA certificate of compliance.

Based on observations during 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.

This had the potential to affect all patients in the facility.

Findings include:

Refer to Life Safety Code violations and A 724.

Based on observation, policy review and interviews with facility staff, it was determined the facility failed to:

a) Ensure equipment was monitored to maintain safety of patients and staff in the therapy department. This had the potential to affect all patients receiving Physical Therapy, Occupational Therapy and Speech Language Pathology Services.

b) Assure safe operation and readiness of the facilities defibrillator's. This affected 2 of 2 emergency crash carts in the facility and had the potential to affect all patients in the facility.

Findings include:

Policy
Subject: Defibrillation Testing - LIKEPAK 9/LIFEPAK 20

...III. Procedure:
The defibrillator is to be checked once every 12 hours noting the following in the log book:
Record the Date of the test
Record the time of the test....
To test - assure the multi function cable is connected to test connector - turn monitor on - turn switch to defib mode - set energy level @ (at) 30 - press Shock button; "TEST OK" should appear on screen...
Record the Expiration Date on the Defibrillator Pads (Adult and Pediatrics)...

1. A tour of the therapy department was conducted on 5/2/12 at 1:50 PM. An operable Hydrocollator was observed with packs present. The surveyor requested the temperature monitoring logs and the current temperature of the contents. The staff was unable to locate a thermometer to check the temperature and there were no temperature monitoring logs available for review.

Further tour of the therapy department revealed a Paraffin Bath that was sitting upon a table top in the treatment room. The surveyor reached to open the lid and it would not open. The surveyor had to forcefully pry the lid open. Employee Identifier (EI) # 6, the Therapy Director stated, "We hardly ever use that". The surveyor asked, "When was it last used?" EI # 6, stated, "I don't know?" There was dried discolored (yellowish) paraffin coated over the entire top of the lid, inside the container and on the outside of the container.

During an interview on 5/2/12 at 2:10 PM, EI # 6, confirmed the above findings. The surveyor requested the therapy departmental policies and procedures. EI # 6 stated, "We don't have any that I am aware of. I think the old company took our policies with them when they left."

An interview conducted on 5/3/12 at 11:00 AM, with EI # 1, the Administrator, confirmed the facility had no therapy policies and procedures.

2. A tour of the Emergency Department was conducted with Employee Identifier (EI) # 3, the Director of Nursing, on 5/1/12 at 1:30 PM. Observation of the Trauma Room revealed two (2) defibrillators (1 Pediatric and 1 Adult). The Biomedical Engineering Sticker on both defibrillators read, "Last Safety Check: Dec (December) 2008". The surveyor asked, "How often are these checked?" EI # 3 replied, "I think yearly?" The surveyor requested the log for preventive maintenance (PM) on the defibrillators. There was no PM log provided to the surveyor prior to the end of the survey.

While assessing the supplies on the pediatric crash cart, the surveyor asked EI # 3 for the pediatric defibrillator pads. There were no pediatric defibrillator pads available.

There was no log book available for the defibrillator testing every 12 hours according to the facility policy.

An interview conducted on 5/3/12 at 12:52PM, with EI # 3 confirmed the aforementioned findings.

Based on interview with the Infection Control staff, facility infection control documentation, and review of Medical Staff Minutes the facility failed to:

1. Ensure a qualified Infection Control Director was appointed as Director of the Infection Control Committee.

2. Establish infection control policies and procedures to ensure a system was in place for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.

3. Maintain a log of incidents related to infections and communicable diseases.

4. Ensure the Infection Control program was reviewed for concerns and interventions put in place.

This had the potential to affect all facility patients.

The findings include:

Refer to A 748, A 749, A 750, and A 756.

Based on interview with Administrative Staff, and a defintition of the "infection control professional" by Centers for Disease Control and Prevention (CDC) the facility failed to ensure a qualified Infection Control Director was appointed as Director of the Infection Control Committee. This had the potential to affect all patients at this facility.

The findings include:

The CDC has defined "infection control professional" as a person whose primary training is in either nursing, medical technology, microbiology, or epidemiology and who has acquired specialized training in infection control.

During an interview on 5/3/12 at 11:30 AM with Employee Identifier (EI) # 2, Quality Director, EI # 3, Director of Nursing, and EI # 4, Assistant Director of Nursing, revealed EI # 2, EI # 3, and EI # 4 were the Infection Control Committee. The surveyor asked what the Infection Control Committee qualifications were and no documentation was supplied to show the Committee had acquired specialized training in infection control.

Based on interviews with the Infection Control staff the hospital failed to establish infection control policies and procedures. This had the potential to affect all patients.

The findings include:

During an interview on 5/3/12 at 11:30 AM, with Employee Identifier (EI) # 2, Quality Director, EI # 3, Director of Nursing, and EI # 4, Assistant Director of Nursing, the surveyor asked for the infection control policies and procedures, EI # 2 stated there were no policies and procedures for the Infection Control Committee to follow for infection control in the facility.

Based on interview with infection control staff and review of facility infection control documentation the facility failed to maintain an infection control log. This potentially affected all inpatients of this facility.

The findings include:

During an interview on 5/3/12 at 11:35 AM, with Employee Identifier (EI) # 2, Quality Director, EI # 3, Director of Nursing, and EI # 4, Assistant Director of Nursing confirmed there was no documentation of a log which identified incidents of infection and communicable disease throughout the hospital and documented infections and communicable diseases in patients and staff.

Based on review of Medical Staff Minutes and interview with Administrative staff the facility failed to ensure the Infection Control program was reviewed for concerns and interventions put in place. This had the potential to affect all facility patients.

The findings include:

During a review of the Medical Staff Minutes on 5/3/12 at 8:15 AM, there was no documentation of a review of the Infection Control Program on the May 2011, November 2011, January 2012, February 2012, March 2012, and April 2012 documents. These Medical Staff Minutes also did not include a discussion of the infection control as part of the quality assurance program.

There was no additional documentation provided to the surveyors of the chief executive officer, medical staff or the director of nursing services reviewing the infection control program.

During an interview on 5/3/12 at 11:35 AM, with Employee Identifier (EI) # 2, Quality Director; EI # 3, Director of Nursing; and EI # 4, Assistant Director of Nursing; when asked if there was a report about tracking and trending infections in their facility; EI # 2, 3, and 4 verified there was no documentation of tracking or tending of infections.

Based on an interview with facility staff it was determined the facility failed to have defined written policies and procedures for rehabilitation services. This had the potential to affect all patients receiving Physical Therapy, Occupational Therapy and Speech Language Pathology Services.

Findings Include:

During a tour of the Outpatient Therapy Department on 5/2/12 at 1:50 PM with Employee Identifier (EI), # 6, the Therapy Director, and EI # 3, the Director of Nursing, the surveyor requested the department's policies and procedures. EI # 6 stated, "We don't have any that I am aware of. I think the old company took our policies with them when they left."

An interview conducted on 5/3/12 at 11:00 PM, with EI # 1, the Administrator, confirmed that there were no therapy policies and procedures.