HospitalInspections.org

Based on review of medical record (MR), hospital policy and staff interview, it was determined the outpatient therapy staff failed to follow their own policy for informed consent. This affected MR # 13, # 14, # 15, 3 of 20 sampled records reviewed and had the potential to negatively affect all patients treated at the facility.

Findings include:

Policy Title: Accuracy and Timeliness of Medical Record Documentation and Whiteboard Validation
Written: 1/1/14

"Purpose:

To define general guidelines for documentation of accurate, timely and complete medical records ...

Policy:

1. A complete, legible and accurate paper and/or electric medical record will be maintained for every individual who is evaluated or treated as an inpatient, outpatient or emergency patient...

...6. A patient's record is complete when the following criteria are met: ... Properly executed informed consent forms."

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1. MR # 13 was admitted to outpatient Physical Therapy (PT) on 5/21/18 with a primary diagnosis of Presence of Right Artificial Knee Joint.

Review of the MR revealed there was no documentation MR # 13 signed a consent for treatment form as directed per the facility policy.

An interview was conducted on 6/25/18 at 2:10 PM with Employee Identifier (EI) # 4, Rehab (Rehabilitation) Director, who confirmed the aforementioned findings.

2. MR # 14 was admitted to outpatient PT on 6/5/18 with a primary diagnosis of Presence of Right Artificial Knee Joint.

Review of the MR revealed there was no documentation MR # 14 signed a consent for treatment form as directed per the facility policy.

An interview was conducted on 6/25/18 at 2:20 PM with EI # 4 who confirmed the aforementioned findings.

3. MR # 15 was admitted to outpatient PT on 5/19/18 with a primary diagnosis of Pain in Right Hand.

Review of the MR revealed there was no documentation MR # 15 signed a consent for treatment form as directed per the facility policy.

An interview was conducted on 6/25/18 at 3:00 PM with EI # 4 who confirmed the aforementioned findings.

Based on review of facility policy and interviews, it was determined the facility failed to ensure all areas of the hospital, including the Laboratory (Lab), Outpatient Rehabilitation (Rehab) Therapy, Radiology and Swing Bed departments, participated in the Quality Assurance Performance Improvement (QAPI) activities. This had the potential to negatively affect all patients served by this facility.

Findings include:

Policy: Quality Assurance and Performance Improvement Plan (QAPI)
Dated: 3/17/18

"Purpose:

Green County Hospital QAPI plan provides guidance for overall quality improvement. ...Focus areas include all systems that affect patient and satisfaction, quality of care and services provided, and all areas that affect the quality of life for persons living and working in the organization.

Services GCHS (Greene County Health System) Provides to Patients

QAPI activities are integrated across all the care and service areas of GCHS.

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1. During a review of the Lab department on 6/25/18 at 10:00 AM, the surveyor asked Employee Identifier (EI) # 3, Lab Supervisor, "What data is the lab department reporting to QAPI?" EI # 3 stated, "I attend the meeting, but I don't report any data." The surveyor then asked EI # 3, "Does the lab have any quality indicators they are monitoring?" EI # 3 responded, "No".

2. During a review of the Outpatient Rehab Therapy area on 6/25/18 at 1:40 PM, the surveyor asked EI # 4, Rehab Supervisor, "What data is the Rehab department reporting to QAPI?" EI # 4 stated, "I attend the meeting, but I don't report any data." The surveyor then asked EI # 4, "Does the Rehab department have any quality indicators they are monitoring?" EI # 4 responded, "No".

3. A review of the facility wide QAPI for January to June 2018 was conducted on 6/27/18 at 12:40 PM with EI # 2, Chief Quality Officer (CQO) and EI # 1,Chief Nursing Officer (CNO).

An interview was conducted on 6/27/18 at 1:00 PM with EI # 1,who confirmed the aforementioned departments were not reporting data to the QAPI committee.


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4. During a review of the Radiology department on 6/26/18 at 1:00 PM, the surveyor asked EI # 8, Radiology Technician, designated as being in charge of the department during the medical leave of the Radiology Director, "What data is the Radiology department reporting to QAPI?" EI # 8 was not aware of any data from the Radiology department being reported to QAPI. The surveyor then asked EI # 8, "Does the Radiology department have any quality indicators they are monitoring?" EI # 8 responded, "Not that I am aware of".

5. During a review of the Swing Bed unit on 6/26/18 at 2:30 PM, the surveyor asked EI # 1, Chief Nursing Officer, "What data is the Swing Bed unit reporting to QAPI?" EI #1 stated, "I don't report any data related to Swing Bed." The surveyor then asked EI # 1, "Does the Swing Bed have any quality indicators they are monitoring?" EI # 1 responded, "No".

An interview was conducted on 6/27/18 at 12:40 PM with EI # 2, who confirmed the above findings.

Based on review of medical record (MR), facility policy and staff interview, it was determined the outpatient rehabilitation (rehab) staff failed to follow the hospital policy for completion of the medical record and discharge summary.

This affected MR # 15, 1 of 3 outpatient rehab sampled records reviewed and had the potential to negatively affect all patients treated at the outpatient rehab department.

Findings include:

Policy Title: Accuracy and Timeliness of Medical Record Documentation and Whiteboard Validation
Written: 1/1/14

"Purpose:

To define general guidelines for documentation of accurate, timely and complete medical records ...

Policy:

1. A complete, legible and accurate paper and/or electric medical record will be maintained for every individual who is evaluated or treated as an inpatient, outpatient or emergency patient...

2. Medical record entries must be completed in real time. Records not completed within 24 hours of discharge are considered delinquent.

3. The following time frames shall be followed when documenting the patient's medical record:

Discharge Summary

A concise discharge summary shall be documented within 10 days post discharge, including the following - ...procedures performed; the care, treatment, and services provided, the patient's condition and disposition at discharge; information must be provided to the patient and family as well as provisions for follow-up care.

...6. A patient's record is complete when the following criteria are met:

*Discharge Summary ... disposition of case and provisions for follow-up care..."

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1. MR # 15 was admitted to outpatient PT on 5/19/18 with a primary diagnosis of Pain in Right Hand.

Review of the MR on 6/25/18 at 2:00 PM revealed a PT Plan of Care dated 5/19/18: ... 2 times a week for 6 weeks.

Review of the PT daily treatment note dated 5/22/18 revealed, "No call, no show for therapy appointment." There was no documentation MR # 15 was contacted regarding the missed appointment.

Review of the PT daily treatment note dated 5/23/18 revealed, "No call, no show for consecutive visits." There was no documentation MR # 15 was contacted regarding the missed appointment.

Review of the MR revealed there was no further documentation in MR # 15's record.

An interview was conducted with Employee Identifier (EI) # 4, Rehab Director. The surveyor asked EI # 4, "What happened to MR # 15"? EI # 4 stated, "She/he was discharged on 5/23/18". The surveyor then requested the discharge summary. There was no discharge summary submitted and EI # 4 stated it had not been completed yet, which was 33 days after discharge.

Based on review of the facility's policies and procedures, observations, and interview it was determined the facility failed to ensure that all:

a) Expired medications were removed and not available for patient use.

b) Multi-dose vial medications available for patient use were labeled with an expiration date.

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

Findings include:

Subject: Expired Drugs
Revision Date: 6-1-18

"Policy:

The pharmacist, pharmacy technical and/or nursing staff shall check all medications (no less than monthly) for expired medications.

Procedure:

...4. Expired Medication is to be pulled and kept for return for credit."

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Subject: Multiple Dose Vials (MDVs) - Use of
Department: Pharmacy
Approved: 5/14/18

"Policy:

Pharmacy Services shall verify that MDVs are stored and labeled correctly when inspecting medication storage areas in the Pharmacy and on patient care units/departments.

...For multidose vials, the expiration will occur 28 days after the vials has been opened/punctured...

Procedure:

...Once a multiple dose vial has been punctured, the staff member shall assign a "beyond use" date to the vial and place this date on the vial's label."

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1. A tour of the Emergency Department was conducted on 6/25/18 at 10:00 AM with Employee Identifier (EI) # 1, Chief Nursing Officer (CNO).

The surveyor observed the following expired medications and 1 (one) MDV opened and not dated:

Trauma Room

a) Pediatric Crash Cart:

Calcium Chloride Injection 10 % (percent) Prefilled Syringes x (times) 2 expiration (exp) date 3/17.

b) Medication Cabinet:

Xylocaine 2 % 1000 milligrams (mg)/50 milliliters (ml) x 1: opened. There was no label indicating the beyond use date as directed per the facility policy.

An interview was conducted on 6/25/18 at 10:25 AM with EI # 1 who confirmed the aforementioned findings.

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 negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations

Based on review of facility policies and procedures, observations, and interview with staff it was determined the facility failed to ensure:

1. supplies available for patient use were not expired.

2. preventive maintenance (PM) was maintained on all equipment.

This did affect medical record (MR) # 16 and # 17 and had the potential to affect all patients served by this facility.

Findings Include:

Subject: Expired Supplies
Revision Date: 6-1-18

"Policy:

Each department manager shall assign one person to check supplies monthly (no less than monthly) for expired supplies.

Procedure:

...4. Expired supplies are to be pulled and discarded once expired."

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Subject: Preventive Maintenance
Revision Date: 6/1/18

"Policy:

Preventive maintenance is part of the planned or scheduled maintenance program of the Greene County Health System. Annual each department manager with (will) check their location to make a scheduled maintenance.

Focus on Major Systems:

...5. Equipment for Patient use

Procedure:

1. Each department manager shall check their department annually to identify each system or item that must be checked and services, and the date it must be serviced.

2. Each department manager must maintain proper documentation that includes a list of the service maintenance and the frequency and interval at which that service is to be performed.

3. The preventive maintenance schedule will be updated each time a system is added, updated, or replaced".

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1. A tour of the Emergency Department was conducted on 6/25/18 at 10:00 AM with Employee Identifier (EI) # 1, Chief Nursing Officer (CNO).

The surveyor observed the following:

Trauma Room

Supplies:

Medication Cabinet: Sterile Transport Swab (culture) x 1: exp 3/16

Equipment:

Goose Neck Lamp, Intravenous (IV) Pump, Welch Allyn Ophthalmic & (and) Otoscope, Glidescope: "Last PM date 5/17 due 5/18".

Lifepak 20 (defibrillator): "Last PM date 5/17 due 11/18". The surveyor asked EI # 1, why this PM sticker was different? EI # 1 stated, "We had a problem with it and it probably needed to be rechecked." EI # 1, then stated, "it has not been".

Pocket Doppler: "Last PM 6/15 due 6/16".

Treatment Room 4:

Pulmo Air and Welch Allyn Ophthalmic & Otoscope: "Last PM date 5/17 due 11/18".

Triage Room

Supplies:

Sterile Transport Swab x 8: exp 3/16

Equipment:

Spot Vital Signs Monitor, Welch Allyn Ophthalmic & Otoscope, Welch Allyn Electric Monitor and Adult Scales: "Last PM date 5/17 due 11/18".

Infant Scales: There was no PM sticker documented on the infant scales. EI # 1 stated, "We just got those." The surveyor asked EI # 1 if biomedical had performed PM on the scales and EI # 1 stated, "No".

Further observation of the Adult scales revealed tape wrapped around a large section of the top portion of the scale.

An interview was conducted on 6/25/18 at 10:25 AM with EI # 1 who confirmed the aforementioned findings.

2. A tour of the Laboratory (Lab) Department was conducted on 6/25/18 at 10:55 AM with EI # 3, Lab Supervisor.

The surveyor observed 2 tray's of red top collection tubes:
1 tray exp 3/18 and 1tray exp 5/18.

An interview was conducted on 6/25/18 at 10:25 AM with EI # 3 who confirmed the 2 trays of collection tubes were expired.

3. An observation of care was conducted on 6/25/18 at 11:55 AM with EI # 5, Licensed Practical Nurse (LPN), Infection Control Nurse, to perform a finger stick blood sugar (FSBS) on MR # 16 in room 103. The surveyor observed an IV pump in MR # 16's room which revealed a PM sticker, "Last PM date 5/17 due 5/18".

4. A medication pass observation was conducted on 6/25/18 at 1:25 PM with EI # 6, Registered Nurse, to MR # 17 in room 105. The surveyor observed an IV pump in MR # 17's room which revealed a PM sticker, "Last PM date 5/17 due 5/18".

An interview was conducted on 6/27/18 at 12:30 PM with EI # 1 who verified the above findings. EI # 1 stated, "The equipment company has now been paid and the PM's can now be performed".




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5.During the tour of the Radiology Department on 6/25/18 at 11:30 AM, the surveyor observed the Ultrasound machine had a PM sticker on it with the "Due Date" of 4/2016. There was no other documentation available to ensure the following Radiology equipment had been checked for hazards:

Ultrasound Machine

An interview was conducted on 6/26/18 at 1:00 PM with a EI # 8, Radiology Technician, who verified the Biomedical sticker on the Ultrasound machine with the due date of 4/2016 was the last preventive maintenance performed.

Based on observations, review of Centers for Disease Control (CDC) hand hygiene guidelines for healthcare settings, facility policies and procedures and interview, it was determine the facility failed to ensure the staff:

1. Performed hand hygiene and gloving per policy.

2. Performed wound care per policy.

3. Maintained equipment and supplies used during wound care after contact with contaminated personal protective equipment (gloves) and contaminated hands.

This affected Medical Record (MR) # 17 and had the potential to negatively affect all patients served by this facility.

Findings Include:

Subject: Handwashing Policy
Revision Date: 2/28/18

"Policy:

Hand hygiene is a critical component of patients' safety and saves lives in health care settings.

Procedure:

The following are times hands should be washed with soap and water but not limited to:

* Before and after removing gloves

* After handing isolation / contamination equipment

Hand sanitizer use

* After contact with inanimate objects in the immediate vicinity of the resident

* After removing gloves..."

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Subject: Glove Policy
Date: 2/14/18

"Purpose:

Hand protection is required when employee's hands are exposed to hazards such as blood or body fluids, potentially infectious material, mucous membranes and intact skin ... and when touching or handing contaminated items or surfaces.

1. Gloves are to be changed when the glove is penetrated by blood or other potentially infectious materials.

2. When contaminated or ... when their ability to function as a barrier is compromised..."

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Policy: Decubitus Care
Approved: 5/14/18

"Purpose:

A. To treat pressure sores already present.

B. To prevent further tissue damage.

Procedure:

... Keep lesions surgically clean."

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CDC Guidelines to Hand Hygiene Volume 51, Published 2002

Recommendations

"1. Indications for handwashing and hand antisepsis

B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1C-J. Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items 1C-J.

C. Decontaminate hands before having direct contact with patients.

F. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient).

G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled.

H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care.

I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

J. Decontaminate hands after removing gloves ..."

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1. MR # 17 was admitted to the facility on 6/18/18 with a primary diagnosis of Seizures.

Review of the MR revealed a physician's order dated 6/18/18 at 7:35 PM as follows: "Clean Stage II pressure to R (right) buttocks BID (two times a day) ... Clean with Dermal Wound Cleanser, pat dry with 4 x (by) 4 and cover with a dressing."

Review of the MR revealed a physician's order dated 6/26/18 and signed off by the physician at 8:00 AM as follows: "Wound care to new open area to right buttock possible Stage II. Clean with Dermal Wound Cleanser, pat dry with 4 x 4. Apply Derma Gran Hydrogel Wound dressing BID. Cover with dressing".

An observation of care was conducted on 6/26/18 at 7:50 AM to observe Employee Identifier (EI) # 7, Registered Nurse (RN), provide wound care to MR # 17's wounds. EI # 10, Patient Care Technician (PCT), assisted EI # 7 with procedure.

EI # 7 had wound care supplies set up on a barrier on the over bed table upon entering the patient's room. EI # 7 washed hands, applied gloves and removed MR # 17's old dressing. EI # 7 then removed his/her gloves and retrieved a cell phone sitting in a chair, took a picture of the wound and placed the cell phone on the bedside table without performing hand hygiene after removing gloves, thus contaminating the equipment (cell phone) and the bedside table.

EI # 7 then performed hand hygiene and proceeded to provide wound care. EI # 7 cleansed both wounds, then applied the Dermal Gran Hydrogel to his/her gloved fingers and applied the Hydrogel to both wounds with his/her fingers without changing gloves between each wound as directed per the facility policy and CDC guidelines.

EI # 7 then assisted EI # 10 in replacing MR # 17's diaper and turn the patient, wearing the same gloves. EI # 7, failed to change gloves and perform hand hygiene.

EI # 7 proceeded to remove 1 glove (R), retrieve supplies from the over bed table with the ungloved hand and place the supplies in the patient's bedside table. EI # 7 then retrieved the contaminated cell phone with the ungloved hand and placed it EI # 10's shirt pocket and collected the red bag and clear bag (tied to the patient's bed - used to place dirty dressing and wound care supplies to provide care) with the ungloved hand. EI # 7 failed to wear gloves, remove gloves and perform hand hygiene as directed per the facility policy.

An interview was conducted on 6/25/18 at 8:30 AM with EI # 1, Chief Nursing Officer, who confirmed the aforementioned findings.

Based on review of medical records (MR) and interview, it was determined the facility failed to ensure the staff in the rehabilitation (rehab) department notified the physician of changes to the patient's plan of care and discharge plans.

This affected MR # 15, 1 of 3 outpatient rehab sampled records reviewed and had the potential to negatively affect all patients treated at the outpatient rehab department.

Findings include:

1. MR # 15 was admitted to outpatient PT on 5/19/18 with a primary diagnosis of Pain in Right Hand.

Review of the MR on 6/25/18 at 2:00 PM revealed a PT Plan of Care dated 5/19/18: ... 2 times a week for 6 weeks.

Review of the PT daily treatment note dated 5/22/18 revealed, "No call, no show for therapy appointment." There was no documentation MR # 15 was contacted regarding the missed appointment.

Review of the PT daily treatment note dated 5/23/18 revealed, "No call, no show for consecutive visits." There was no documentation MR # 15 was contacted regarding the missed appointment.

Review of the MR revealed there was no further documentation in MR # 15's record.

An interview was conducted with Employee Identifier (EI) # 4, Rehab Director. The surveyor asked EI # 4, "What happened to MR # 15"? EI # 4 stated, "She/he was discharged on 5/23/18". The surveyor then requested the discharge summary. There was no discharge summary submitted and EI # 4 stated it had not been completed yet, which was 33 days after discharge.

The surveyor then asked EI # 4 if the physician was notified that MR # 15 did not show for treatments and the plan for discharge. EI # 4, "Yes, but it's not documented".

Based on review of medical record (MR), Swing Bed Utilization Activities Protocol, Individiual Resident Activities form, and staff interviews, it was determined the facility failed to ensure all patient activity needs and goals for care were met, which included documentation of activities planned, organized and offered during normal waking hours.

This affected 2 of 2 Swing Bed discharged patient records, including MR #11 and # 12, and had the potential to negatively affect all patients admitted to the Swing Bed unit.

Findings include:

Subject: Swing Bed Utilization - Activities Protocol
Reviewed: No Date

"Should any patient be admitted to a bed categorized as a swing bed patient, it is understood that as a part of the assessment protocol, a complete regimen of activities will be provided based on need and assessment of the patient....

A calendar of events would be established and posted at the nurse's desk, in the patient's swing bed record and on the wall in the room where the patient is admitted."

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1. MR # 11 was admitted to the Swing Bed unit on 1/16/18 with diagnoses including Generalized Weakness, Coronary Artery Disease and Status-post Coronary Artery Bypass Graft.

Review of the Initial Activities Evaluation, that was not dated, revealed activities of interest identified were watching television, going to the Barber, cooking/baking, current events, playing dominoes, exercise, movies, music, radio, walking and writing.The frequency of activites to be offered was documented as 2 times per week in the patient's room.

Review of the Individual Resident Activities form revealed no documented activities for the following dates: week of 1/27/18, week of 2/1/18.

There was no activity calendar provided to the surveyor for MR # 11 for the Swing Bed admission dates of 1/16/18 to 2/15/18. There was no activity calender in the closed MR as per facility process.

On 6/26/18 at 9:45 AM, Employee Identifier (EI) # 9, Activities Director, provided the surveyor with a monthly activity calendar schedule for June 2018, which was the current calendar being used in the Nursing Home. EI # 9 stated there was no calendar specific to the Swing Bed unit.

In an interview on 6/27/18 at 1:15 PM, EI # 1, Chief Nursing Officer, confirmed the above findings.

2. MR # 12 was admitted to the Swing Bed on 12/19/17 with diagnoses including Shortness of Breath and Deconditioning Chronic Obstructive Pulmonary Disease.

Review of the Initial Activities Evaluation dated 12/27/17, revealed activities of interest identified were Bingo, cards, cooking/baking, current events, family/friends visits, gardening, movies, and shopping. The frequency of activities to be offered was documented as 2 times per week in the patient's room.

Review of the Individual Resident Activities form revealed no documented activities for the following dates: week of 12/19/17 and 12/22/17.

There was no activity calendar provided to the surveyor for MR # 11 for the Swing Bed admission dates of 12/19/17 to 1/3/18. There was no activity calender in the closed MR as per facility process.

On 6/26/18 at 9:45 AM, Employee Identifier (EI) # 9, Activities Director, provided the surveyor with a monthly activity calendar schedule for June 2018, which was the current calendar being used in the Nursing Home. EI # 9 stated there was no calendar specific to the Swing Bed unit.

In an interview on 6/27/18 at 1:15 PM, EI # 1 confirmed the above findings.