HospitalInspections.org

This condition was cited based on review of the hospital's Quality Assessment and Improvement Plan/Program (QA IP), review of the Hale County Health Care Authority Board of Directors (otherwise known as the Board) meeting minutes and interview with the Quality Assurance (QA) Coordinator/ Director of Nursing (DON), it was determined the Governing Body (Board) failed to ensure:

1. There was an ongoing QAIP program to measure, track and analyze departmental indicators to make changes to improve patient care and outcomes.

2. Medications were securely stored and not expired.

3. Quarterly pharmaceutical and Therapeutics Committee meetings were conducted.

4. Policies were developed and implemented for the management of home medications.

Findings include:

Refer to A 263 and A 490

This condition level deficiency is written as a result of the hospital failing to maintain an ongoing quality patient care, analyze data, monitor adverse events, implement action plan to improve patient care outcomes and follow-up review to ensure quality patient care is consistently achieved. As a result of the recertification survey the areas of concern includes the following:

1. Failure to monitor and track the department's quality indicators and other aspects of hospital services and operations.
Refer to A- 273.

2. Failure to implement and document corrective actions for identified problems.
Refer to A- 283.

3. Failure to identify improvement activities and progress towards goals.
Refer to A- 297

4. Failure to identify projects and reasons for conducting these projects.
Refer to A- 308

Based on review of the hospital policy, Quality Assessment and Improvement Plan and interview with the Quality Assurance (QA) Coordinator/ Director of Nursing (DON), it was determined the facility failed to monitor and track the department's quality indicators and other aspects of hospital service and operations. This had the potential to negatively affect all patients served by the hospital.

Findings include:

Hale County Hospital Quality Assessment and Improvement Plan

Purpose

" The purpose of Quality Assessment and Improvement Program for Hale County Hospital is to establish, organize, implement, monitor and document evidence of an ongoing and systematic Quality Assessment and Improvement Process that includes effective mechanisms for reviewing and evaluation the care provided to patients including all age groups to ensure one level of care.

Objectives

1. Implementing a planned, systematic and ongoing process for monitoring, evaluating and improving the quality and appropriateness of care provided to patients.
...
4. Designing an evaluation process that will determine the presence or absence of an opportunity to improve on a problem, in the quality and/ or appropriateness of care.

5. Determining how problems can be corrected and whether care can be improved.
...
9. Overseeing and evaluating the effectiveness of quality assessment and improvement activities and modify as necessary to better monitor care provided to patients.

10. Continue educational process and implement continuous quality improvement."

Review of the Quality Assessment and Improvement Plan conducted on 2/25/15 at 3:15 PM with Employee Identifier (EI) # 2, QA Coordinator/ DON revealed all department submits a quality review to the QA Coordinator/ DON monthly the surveyor asked what was the next step after gathering all the data submitted, the QA Coordinator/ DON stated that she/ he just gathers data and places it in a 3 ring binder.

An interview was conducted on 2/25/15 at 3:15 PM with Employ EI # 2, who confirmed the above mentioned findings.

Based on review of the hospital policy, Quality Assessment and Improvement Plan departmental audits and interview with the Quality Assurance (QA) Coordinator/ Director of Nursing (DON), it was determined the hospital failed to implement corrective actions focusing on performance improvement, ensure actions taken have a positive affect on patient outcomes, safety and quality of care. This had the potential to negatively affect all patients served by the hospital.

Findings include:

Hale County Hospital Quality Assessment and Improvement Plan
...

Communications

" The results of the monitoring and evaluation process are communicated to relevant individuals, departments, or services and to the organization wide Quality Assessment and Improvement Program."

Review of the Quality Assessment and Improvement Plan on 2/25/15 revealed no documentation of corrective actions implemented.

An interview was conducted on 2/25/15 at 3:15 PM with Employee Indentifer (EI) # 2, QA Coordinator/ DON who confirmed the above mentioned findings.

Based on review of the hospital policy, Quality Assessment and Improvement Plan and interview with the Quality Assurance (QA) Coordinator/ Director of Nursing (DON) it was determined the facility failed to document reasons for conducting identified projects and progress to goals achieved. This had the potential to negatively affect all patients served by the hospital.

Findings include:

Hale County Hospital Quality Assessment and Improvement Plan

Clinical Indicators

" In order to assess structure, process or outcome, clinical indicators which are well defined, measurable and based on major aspects of care will be developed for the purpose of identifying trends or patterns of care that may not be evident when only case-by-case review is performed.

Evaluation

When pre-established thresholds are reached, care will be evaluated to identify patterns of performance, or opportunities to improve patient care. Evaluation will include causative analysis from which conclusions will be made. ..

Actions

When problems or opportunities to improve patient care are identified, appropriate corrective action plans will be developed and implemented.

Assessment

Problems, trends or opportunities to improve patient care will be re-evaluated to determine the effectiveness of action taken. Periodic follow-up will continue until significant resolution/ improvement is documented."

Review of the Quality Assessment and Improvement Plan audits January to December 2014 revealed no documentation of actions taken to correct identified problems/ projects.

An interview was conducted on 2/25/15 at 3:15 PM with Employee Identifier (EI) # 2, QA Coordinator/ DON who confirmed the above mentioned findings.

Based on the review of the hospital Quality Assessment and Improvement Plan (QA IP), review of the minutes of the Hale County Heath Care Authority, Board of Directors (Otherwise known as the Board) meeting and interview with the Quality Assurance (QA) Coordinator/ Director of Nursing (DON) it was determined the facility failed to ensure the QA IP is actively meeting and discussing issues identified by each department. This had the potential to affect all patients served by this facility.

Findings include:

During the interview with the Employee Identifier (EI) # 2, QA Coordinator/ DON conducted 2/25/15 at 3:15 PM the surveyor asked how often the members of the QA Team and she/ he stated the committee did not meet year 2014 and had not met since she/ he became the QA Coordinator.

Review of the Board meeting minutes for 2014 revealed the following:

February 28,2014- Board met, there was no documentation of QA IP activities or findings.

April 22,2014 - Board met, there was no documentation of QA IP activities or findings.

May 2014 - No meeting

June 9, 2014 - Board met, there was no documentation of QA IP activities or findings.

July 1, 2014 - Board met, there was no documentation of QA IP activities or findings.

July 29, 2014 - Board met, there was no documentation of QA IP activities or findings.

August 26, 2014 - Board met, there was no documentation of QA IP activities or findings.

September 2014 - No meeting

October 2014 - No meeting

November 18, 2014 - Board met, there was no documentation of QA IP activities or findings.

December 2014 - No meeting.

Hale County Hospital Quality Assessment and Improvement Plan

Board of Directors

" The Board of Directors shall maintain ultimate responsibility for the Quality Assessment and Improvement Program, striving to assure quality patient care by requiring and supporting the establishment and maintenance of an effective hospital wide quality assessment and improvement program.

The Board delegates the authority to perform this function to the Medical Staff through the Medical Executive Committee and Administrator, but the Board will:

- receive and review periodic reports of findings, actions, and results of actions from the Quality Assessment and Improvement Program;

- approves the QA IP which includes an assessment of the program's efficiency and effectiveness on an annual basis;

- recommend appropriate organizational and/ or activity modification;

- assure that the primary goal of patient care enhancement is achieved."

An interview was conducted on 2/25/15 at 3:15 PM with EI # 2, who verified the above mentioned findings.

Based on review of medical records, policy and procedures, Alabama Board of Nursing Standards of Practice and interviews it was determined the nursing staff failed to:

1. Document specific wound care provided

2. Document wound assessments to include appearance of the wound/ wound bed, exudates, drainage, odor signs and symptoms of infection' skin surrounding the wound and measurement.

3. Document the skin surrounding the wound

4. Document education to caregiver or patient related to wound care after discharge.

5. Document weights as ordered.

6. Administer medications as ordered.

8. Ensure staff monitored the nurse unit crash cart and defibrillator per policy.

This had the potential to affect all patients served by the facility and did affect 7 of 12 Medical Records (MR) including MR # 1, # 6 # 7 and # 9, and Swing Bed MR's # 2, # 3, and # 4.

Findings include:

Hale County Hospital (HCH) Policy Wound (Decubiti) Assessment and Documentation

Written: 06/09/10

The following is the policy and procedure for the proper documentation of assessment for patients that have wound (decubiti).

Responsibility for completion of Wound Assessment Form:
...
2. " The wound assessment form must be completed each day, once per day, by the licensed nurse performing the wound treatment.

The wound assessment form is otherwise self explanatory for what other information should be included. See Attached Wound Assessment Form.

The Wound Assessment Form is yellow in color."

HCH Wound Assessment Form
...

" Description of Treatment for Ulcer __________...
...

Date Time Nurse Signature of Treatment Complete."


Alabama Board of Nursing Chapter 610-X-6
Standards of Nursing Practice

610-x-6-.13 Standards for Wound Assessment and Care

(1)" It is within the scope of a registered nurse or licensed practical nurse practice to perform wound assessments including, but not limited to, staging of a wound and making determinations as to whether wounds are present on admission to a healthcare facility pursuant to an approved standardized procedure..."

(2) " The minimum training for the registered nurse or licensed practical nurse that performs selected tasks associated with wound assessment and care shall include:
(a) Anatomy, physiology and pathophysiology.
(c) Equipment and procedures used in wound assessment and care.
(d) Chronic wound differentiation.
(e) Risk identification.
(f) Measurement of wound.
(g) Stage of wound.
(h) Condition of the wound bed including:
(i) Tissues
(ii) Exudates
(iii) Edges
(iv) Infection
(i) Skin surrounding the wound."

610-X-6-.06 Documentation Standards

(1)" The standards of documentation of nursing care provided to patients by registered nurses or licensed practical nurses are based on principles of documentation regardless of the documentation format.

(2) Documentation of nursing care shall be:
(a) Legible
(b) Accurate
(c) Complete. Complete documentation includes reporting and documenting on appropriate records a patient's status, including signs and symptoms, response, treatments, medications, other nursing care rendered, communication of pertinent information to other health team members, and unusual occurrences involving the patient."

1. MR # 6 was admitted to the hospital on 9/27/14 with the diagnoses including Urinary Tract Infection, Open Wound Right Leg and Chronic Stage IV on Coccyx and Bilateral Hips.

The Physician Entered Order 9/27/14 written by Employee Identifier (E) # 10, Certified Registered Nurse Practitioner (CRNP) for daily weights and wound care to right lower leg, clean wound with peroxide/ saline then apply Bactroban dress with 4x4 gauze 2 times a day.

Review of the Registered Nurse (RN) notes 9/28/14, 9/29/14, 9/30/14, 10/1/14 and 10/2/14 revealed there was no documentation wound care was provided, the wound was measured and assessed.

Further review of the RN notes dated 9/28/14, 9/29/14, 9/30/14, 10/1/14 and 10/2/14 revealed documentation the daily weights were not taken as ordered.

An interview was conducted on 2/26/15 at 9:15 AM with Employee Identifier (EI) # 2, Director of Nursing (DON) who confirmed the above mentioned findings.

2. MR # 7 was admitted to the hospital on 2/3/15 with the diagnoses including Open Wound Hip, Degenerative Joint Disease, Knees, Hypertension and Status Post Colostomy.

Physician Entered Orders 2/3/15 written by EI # 10 had the following wound orders: "wet to dry dressing to coccyx 2 times a day, pack left hip with saline soaked 2 inch kling 2 times a day and Maxorb Extra wet with saline then pack with 2 inch kling to left hip every morning."

Review of the RN note 2/5/14 revealed documentation the left hip wound care was cleaned with saline and Betadine- size 4x4, packed with Microderm and wet to dry dressing applied. There was no physician order for the wound care performed.

Physician Entered Orders 2/6/15 written by EI # 10 for wound care was revised to: "Dakin's Solution dressing to wound bed left hip 2 times a day apply Dakin's solution to wound bed. Don't get any on the good tissue."


Review of the RN notes dated 2/4/15, 2/5/15, 2/6/15, 2/7/15, 2/8/15 and 2/9/15 revealed there was no documentation wound care was provided as ordered.

An interview was conducted on 2/28/15 at 9: 30 AM with EI # 2 who confirmed the above mentioned findings.




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3. Swing Bed MR # 2 was admitted to the unit on 2/13/15 with a diagnosis status post fall with contusion of right hip/leg.

Record review revealed the patient was a Type II Diabetic, requiring insulin per sliding scale. Review of the 2/19/15 7:00 AM nurse problem activity document and medication record document revealed a blood glucose of 175, Intervention: Not given. 2 units of Novolin R (regular) insulin was ordered. The two documents revealed insulin was not administered.

A written inquiry, presented to EI # 1, Chief Executive Officer (CEO)/Administrator on 2/25/15 at 4:00 PM and received on 2/26/15 at 10:40 AM confirmed insulin was not administered as ordered.

4. Swing Bed MR # 3 was admitted to the unit on 1/12/15 with a diagnosis of Weakness and Fall risk.

Review of the Swing Bed Service document, signed by the patient included weights will be taken once a week unless specified by the physician.

The 1/12/15 admitting weight was 178 lbs (pounds). The next weight documented was 1/26/15, 162.2 lbs. There was no weight documented for the week of 1/16/15.

Record review revealed 1/14/15 nurse documentation the patient had a skin tear to the left forearm. The nurse documented, dressing changed to skin tear to left arm. Cleaned with NS (normal saline) and applied Polysporin ointment 4 x 4 gauze and secured with paper tape.

Record review revealed on 1/15/15 the nurse documented neosporin and 4 x 4 (gauze) dressing applied to left FA (forearm).

There was no physician's order for the wound care performed. There were no wound assessments documented that included the left forearm skin tear size, wound observations including the presence of drainage, pain and appearance of surrounding skin.

A written inquiry, presented to EI # 1 on 2/25/15 at 4:00 PM, received on 2/26/15 at 10:40 AM confirmed the aforementioned findings.

5. Swing Bed MR # 4 was admitted to the unit on 2/9/15 with a diagnosis of Severe Weakness, Improving Dysphagia and Diabetes Mellitus, Type II.

Review of the Swing Bed Service document, signed by the patient included weights will be taken once a week unless specified by the physician.

The 2/9/15 admitting weight was 240 lbs. The next weight documented was 2/22/15, 238 lbs. There was no weight documented for the week of 2/16/15.

Record review revealed MR # 4 required Novolin R (regular) insulin per 2/17/15 sliding scale order. Review of the 2/19/15 6:59 AM Diabetic Flowsheet and medication record documentation revealed a blood glucose of 163, Intervention: 2 units of Novolin R (regular) insulin (for blood glucose 150-199), "Not given". The nurse documentation revealed the sliding scale insulin was not administered as ordered.

6. MR # 1 was admitted to the medical unit 2/17/15 with diagnoses including Acute Cellulitis to the Lower Extremities and Diabetes Mellitus.

Review of 2/17/15 3:08 PM physician's orders included daily weights.

Review of the daily nurse progress note documentation failed to include weights 2/18/15, 2/21/15 and 2/23/15.

Review of 2/18/15 4:27 PM physician's orders included wet-dry dressings to lower legs twice daily after showering. The order did not specify what solution was to be applied to wet the dressing. There was no documentation the RN contacted the physician to clarify the wound order.

Review of the 2/18/15 nurse progress note failed to include wound assessment documentation.

Review of 2/18/15 4:28 PM physician's orders included moist heat wraps to lower legs 20 minutes three times a day.

Review of the 2/19/15 8:30 AM nurse progress note documentation revealed the following: "...Incisions/Dressings: Wet to dry, Dressing changed. Wound Assessment: See Wound Assessment Flowchart. The 2/19/15 documentation did not include wound assessment.There was no documentation of the specific solution applied to wet the dressing. There was no documentation moist heat wraps were applied to lower legs 20 minutes three times on 2/19/15.

Review of 2/20/15 9:24 AM physician's orders revealed staff to bathe legs with Hibiclens-patient unable to reach.

Review of the 2/20/15 and 2/21/15 nurse progress notes failed to include wound assessment documentation. There was no documentation the patient's legs were bathed with Hibiclens. There was no documentation moist heat wraps were applied to lower legs 20 minutes three times on 2/20/15 and 2/21/15.

Review of the 2/22/15 nurse progress note failed to include wound assessment documentation. There was no documentation moist heat wraps were applied to lower legs 20 minutes three times on 2/22/15.

Review of the 2/23/15 nurse progress note failed to include wound assessment documentation. There was no documentation wound care was performed. There was no documentation moist heat wraps were applied to lower legs 2/23/15 prior to the 3:22 PM transfer to the swing bed unit.

7. MR # 9 was admitted to the medical unit 1/20/15 with diagnoses including Uncontrolled Diabetes Mellitus (DM) and Hypertension.

Review of the 1/23/15 physician history and physical documentation revealed Lantus insulin was started along with SSI (sliding scale insulin) due to uncontrolled DM.

Record review revealed blood glucose testing was performed 4 times daily at 7:00 AM, 11:00 AM, 4:00 PM and 9:00 PM. Physician orders were Lantus insulin 15 units at bedtime on 1/21/15, increased to 20 units at bedtime on 1/22/15.

Review of the MR # 9's medication record revealed Regular insulin (Novolin R) 100 units/milliliter for sliding scale protocol was administered 1/20/15 at 9:14 AM to 1/23/15 at 11:42 AM for blood glucose levels greater than 150 (grams/deciliter).

Review of the 1/22/15 9:51 PM blood glucose level was 280. There was no documentation Regular sliding scale insulin was administered as ordered.

In a 2/26/15 10:40 AM interview with EI # 2 confirmed staff failed to administer the sliding scale insulin as ordered.


Review of the 2015 nurse unit Crash Cart Checklist on 2/24/15 at 11:10 AM revealed no documentation the cart was checked and required documentation the date, time and signature of the person who performed the crash cart check on the following dates:
1/6/2015
1/10/2015
1/11/2015
1/15/2015
1/16/2015
1/17/2015
1/18/2015
1/25/2015
1/29/2015
2/5/2015
2/7/2015
2/8/2015
2/9/2015
2/10/2015
2/14/2015
2/15/2015
2/16/2015
2/20/2015

During an interview with EI # 6, Registered Nurse (RN), Charge Nurse on 2/24/15 at 11:15 AM, confirmed staff failed to perform and document crash carts monitoring per facility policy.

This condition of participation for Pharmaceutical Services is out of compliance based on observation, review of Quarterly Pharmacy and Therapeutics Committee meeting minutes, review of policy and procedures and review of Medication Administration records.

The facility failed to:

1. Store medications, keep the controlled medications secured and manage medications according to policy. Refer to A 500 and A 503

2. Conduct Quarterly Pharmacy and Therapeutics Committee meetings. Refer to A 492

3. Develop and implement a policy for home medication management. Refer to A 500.

4. Ensure all medications and biological's available for patients were not expired. Refer to A 505

This had the potential to affect all patient served by the facility.

Findings include:

Refer to A 492, A 500, A 503 and A 505 for findings.

Based on review of facility policy and procedures, Pharmacy Consulting Pharmacist Monthly Report and staff interviews, it was determined the facility failed to conduct Pharmacy and Therapeutic (P&T) committee meetings.

Findings include:

Subject: Pharmacy and Therapeutic Committee
Revised: 11/98

" It is the policy of Hale Country hospital to address pharmacy and therapeutic issues at monthly Medical Staff meeting and Nursing Service meetings..."

Policy: Meetings
Written: June 2005

" Infection Control, Pharmacy...meetings will be held in conjunction with monthly Medical Staff, Departmental Meetings..."

Findings include:

Review of the Hale County Hospital Department of Pharmacy Consulting Pharmacist monthly reports for 2014 did not include development, coordination and/or participation in Pharmacy and Therapeutic meetings.

During a 2/25/15 1:45 PM phone interview with Employee Identifier (EI) # 3, Consulting Pharmacist, reported the facility did not have documentation of minutes of committee meetings with facility staff regarding pharmaceutical services.

In an 2/25/15 2:20 PM interview with EI # 1, Chief Executive Officer/ Administrator confirmed the facility failed to conduct P&T meetings.

Based on review of facility policy and procedure, observations and staff interview, it was determined the facility failed to:

a) Ensure refrigerator temperatures were within acceptable ranges for medication storage.

b) Develop and implement a policy for home medication verification.

This had the potential to affect all patients served by the facility.

Findings include:

Facility Document
Title: "Temperature Regulation of Refrigerator...

Temperatures shall be recorded and kept on file of (for) all refrigerators...A thermometer should be located in each refrigerator...and recorded...Refrigerator...temperatures shall be within the acceptable range of 34 to 40 Degrees (Fahrenheit)...At any time any refrigerator...is not within the acceptable range, it must be reported to Plant Operations immediately."


During a 2/24/15 11:34 AM tour of the nursing department, a refrigerator in the Clean Utility room was found to have the following stored in it:

1. A metal box with a pad lock on it with Eighteen injectable Ativan 2 milligram (mg)/milliliter vials.
2. Nine open insulin vials.

The refrigerator had a Monthly Temperature Range Chart, dated October 1 to 9, 2013 taped to the door.

The surveyor asked Employee Identifier (EI) # 6, Registered Nurse, Charge Nurse, if the refrigerator temperature was being monitored. EI # 6 reported staff had not monitored the refrigerator temperature.

The facility was unable to determine that Ativan and insulin which required refrigeration were kept within an acceptable temperature range.

In a 2/25/15 1:30 PM interview with EI # 1, Chief Executive Officer, Hospital Administrator, the finding was confirmed.

2. During a medication pass observation on 2/25/15 at 8:45 AM with the Licensed Practical Nurse, EI # 8, Metformin 850 mg was administered from a patients home prescription bottle.

During observations of medication management on the nursing unit and interview with EI # 6 on 2/25/15 at 10:30 AM, EI # 6 was asked how patient home prescription medications are verified as accurate before dosing. EI # 6 reported use of a written description of the medication on the prescription bottle (if available), a nursing drug reference or the PDR (physician's desk reference) is used.

In an interview on 2/25/15 at 1:45 PM with EI # 1 confirmed the facility did not have a policy for home medication verification. EI # 1 reported staff can also use the Internet to verify patient home medications.

Based on review of facility policy and procedure, observation and staff interviews, it was determined the facility failed to secure storage of controlled drugs. This had the potential to affect all patients served by the facility.

Findings include:

Subject: Controlled Substances
Revised: 11/97

Policy

"Narcotics, barbiturates, and other controlled substances must be handled and secured in accordance with Federal and State requirements.
They must be kept under double lock at all times..."


During a 2/24/15 11:34 AM tour of the nursing department, a refrigerator in the Clean Utility room was found to have a metal box with a pad lock on it.

The surveyor asked EI # 6, Registered Nurse, Charge Nurse, what was in the metal locked box. The box was opened at request of the surveyor. Eighteen injectable Ativan 2 milligrams/milliliter vials (controlled substance schedule IV) were in the unlocked refrigerator in the unlocked Clean Utility room.

The facility failed to ensure controlled drugs were secured as per policy under double lock at all times.

In a 2/25/15 1:30 PM interview with EI # 1, Chief Executive Officer/ Hospital Administrator, the finding was confirmed.

Based on review of policy and procedure, observations and interview, it was determined the facility failed to ensure:

a) all biologicals in patient treatment areas were not expired.

b) all biologicals in use were correctly labeled.

This had the potential to negatively affect patients receiving care from surgery services.

Findings include:

Nursing Service
Subject: Out-Of-Date-Drugs
Revised:11/97

Policy:

"Drugs throughout the hospital are inspected monthly by the Consulting Pharmacist and/or his designee..for out- of- date drugs. Drugs that are outdated or that will expire before the next inspection are pulled and placed in a container marked Caution: OUTDATED DRUGS-DO NOT USE..."


Centers for Disease Control and Prevention

4. "When should multi-dose vials be discarded?

Medication vials should always be discarded whenever sterility is compromised or questionable.
In addition, the United States Pharmacopeia (USP) General Chapter 797 [16] recommends the following for multi-dose vials of sterile pharmaceuticals:
If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial."


1. During the tour of the Emergency Department (ED) Medication Room on 2/25/15 with the Employee Identifier (EI) # 9, Licensed Practical Nurse (LPN), the following medications were found dated greater than 28 days.

1. Labetalol Hydrochlorothiazide 1 gram injectable labeled opened 11/2014.

An interview was conducted on 2/25/15 at 10:45 AM with EI # 2 who confirmed the above mentioned findings.


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2. During a tour of the nurse unit on 2/24/15 at 10:55 AM, 9 sterile culture collection and transport system swabs, expired 9/2014 were found in the nurse office on the nursing unit.

3. On 2/24/15 at 11:34 AM in the nursing department, a refrigerator in the Clean Utility room was found to have the following outdated medications:
One 0.9 % Sodium Chloride 10 milliliter (ml) syringe expired 11/2011
Eight Phenadoz 12.5 milligram (mg) rectal suppositories, expired 4/2013

On the storage shelf in the Clean Utility room, one quart bottle of Similiac Sensitive infant formula, expired 12/1/14 was found.

4. During observations on the nurse unit and interview with EI # 6 on 2/25/15 at 10:30 AM, the following medications were found on the nurse medication cart and not labeled for use:
1 bottle CQO 10 200 milligrams (mg), 1 tablet
1 bottle Divalproex Sodium 125 mg, 2 tablets
Fluticasone Proponate 50 microgram, 1 inhaler

The following medications were found in the patient medication cart, reported by EI # 6 to belong to discharged patients (prescription labels were on the medication bottles):
Cyclobenzaprine 10 mg 1 by mouth at bedtime
Tramadol Hydrochloride 50 mg 1-2 as needed for pain

The following labeled medications were found in the locked medication cabinet at the nursing station. The medications were reported to be discharged patients medications left at the facility per EI # 6:
Magnesium Oxide 400 mg 1 tablet daily
Sertraline Hydrochloride 100 mg 1 1/2 tablets by mouth daily.

In an interview on 2/25/15 at 11:00 AM with EI # 6, Registered Nurse, Charge Nurse confirmed there were unlabeled medications and discharged patient home medications on the patient medication cart. Home medications had not been removed from the nursing unit after the patients were discharged. There were expired biologicals and medications not removed from the nursing unit.

Based on observations, CDC (Centers for Disease Control ) guidelines for hand hygiene in health care settings, facility policy for hand hygiene and EvenCare Glucometer use and interviews, it was determined the staff failed to:

1. Perform hand hygiene per facility policy and CDC guidelines .

2. Maintain and clean equipment to prevent potential infection to patients and/or staff by use.

This had the potential to affect all patients served by this facility and staff.

Findings include:

www.cdc.gov
Morbidity and Mortality Weekly Report
Recommendations and Reports October 25, 2002 / Vol. 51 / No. RR-16
Centers for Disease Control and Prevention

Guideline for Hand Hygiene in Health-Care Settings
Recommendations for Hand Hygiene

" 1...
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, lifting a patient)
I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient
J. Decontaminate hands after removing gloves..."

2. Hand-hygiene technique...
B. When washing hands with soap and water...Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet (IB) (90-92,94,411)..."

Facility Document
Subject: Handwashing

Handwashing is the single most effective deterrent to the spread of infection

Policy

Hospital personnel shall wash their hands to prevent the spread of infections:

"...2. Before applying and after removing gloves...
4. Between handling of individual patients...

Procedure:
...5. Dry hands well with paper towels, then use the paper towel to turn off faucet..."


Centers for Disease Control and Prevention
January 4, 2012
"Infection Prevention during Blood Glucose Monitoring and Insulin Administration

·FAQs: Blood Glucose Monitoring and Insulin Administration ..........

The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration.

CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements:.....Fingerstick devices should never be used for more than one person. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared.... "

Facility Document

EvenCare G2 Blood Glucose

Intended Use:
"The EvenCare G2 Blood Glucose Monitoring System is intended...for both lay use...and in a clinical setting by healthcare professionals..."

1. During an observation of care on 2/25/15 at 8:05 AM with Occupational Therapist, Employee Identifier (EI) #4, completed the therapy session, went to the sink in the patient's room, performed hand hygiene and turned off the faucet with clean hands.

EI # 4 did not turn off the faucet with a paper towel.

In an interview on 2/26/15 at 12:30 PM with EI #1, Chief Executive Officer/Administrator confirmed staff did not follow the facility policy for hand hygiene.

2. On 2/24/15 at 11:20 AM the surveyor observed EI #5, Laboratory Department Manager check the blood glucose for 2 unsampled patients using an EvenCare glucometer. EI # 5 donned gloves upon entry into the patient's room, performed the blood glucose test and exited the patient room wearing gloves used during the blood glucose testing.

EI # 5 did not perform hand hygiene prior to donning gloves. EI # 5 did not clean the EvenCare glucose monitor after checking the first patient's blood glucose. EI # 5 did not wash his/her hands after completing blood glucose testing and after glove removal.

EI # 5 removed and discarded his/her gloves after entering the second patient's room.

EI #5 did not clean the glucose monitor after patient use.

EI # 5 performed the blood glucose test for the next patient using the Even Care glucose monitor. EI # 5 removed his/her gloves and and placed the gloves in the trash in the patient's room. EI # 5 did not perform hand hygiene after glove removal and before donning clean gloves.

EI # 5 exited the patient room to nursing station counter. EI # 5 documented the blood glucose results in the manual at the nursing station.

EI # 5 did not clean the EvenCare Blood Glucose monitor according to CDC guidelines after patient use. EI # 5 did not follow CDC guidelines for hand hygiene.

An interview conducted on 2/25/15 at 8:20 AM with EI # 5, confirmed the EvenCare blood glucose monitor was not cleaned between patient use and hand hygiene was not performed per CDC requirements and facility policy.

Based on review of facility policies and procedures, Swing Bed medical records (MR) and interview, it was determined the facility failed to complete a comprehensive assessment and establish a care plan to meet the needs identified for 3 of 3 patients residing in swing beds. This did affect Swing Bed MR's # 2, # 3 and # 4 and had the potential to affect all patients receiving services in swing beds.

Hale County Healthcare Authority
Policies and Procedures
Swing Bed/Patient Care Services
Original Date:2010 (no revised date)

Swing Bed Admission Procedure

" Procedure

...The patient's attending physician is to order a consult...
After review, the Swing Bed Team will notify the physician and family of...eligibility...The unit clerk is to...implement a new chart utilizing the Swing Bed chart and forms:
...Swing Bed Interdisciplinary Patient Education/Goal/Outcomes Record..."

Swing Bed/Patient Care Services
Original Date: (blank) Revision: (blank)

Swing Bed Interdisciplinary Patient Education/Goals/Outcomes Record

Policy

Each swing bed patient shall have an Interdisciplinary Patient Education/Goals/Outcomes Record maintained in the patient's medical record.

Procedure
"The Interdisciplinary Record will be initiated by the admitting nurse and Social Services during the swing bed admission process...
Social Services, in conjunction with nursing, will complete the...from indicating problems, goals, approached, etc.

Social Services is responsible for oversight of the record.
After collaboration with social services, revisions are made to the record as identified, or at least weekly by the Social Services department. The plan is reviewed weekly at the Interdisciplinary Discharge Planning meeting.

The following disciplines participate in patient care planning:
Medical
Nursing
Dietary
Social Services
Physical Therapy
Education
Pharmacy
Infection Control
Other disciplines as appropriate

Planning for patient care shall include the following:
Patients needs...assessed on admission...and at least weekly.
Diagnosis...discussed...prioritized by the patient/family...and the Interdisciplinary team.
Planning and Setting goals...Goals will be stated in behavioral terms...be realistic, specific and measurable. Social Services will oversight (oversee) goals.
Implementation: Discipline specific interventions shall be formulated...each identified problem/goals. Interventions...specific, include target dates...identify the person responsible for carrying out the intervention...
Evaluation: Progress toward goal achievement...evaluated on or before the established target date and shall be documented...Goals/interventions...accomplished or reviewed shall be indicated on the care plan."

Facility Document
Title: Dietary Consultant's Assessment Policy

"Nutritional assessments are completed upon physician's request. Recommendations are discussed with the physician if available, if not the recommendation is given to the nurse assigned to the patient. The nurse reports this assessment to the physician and gets an order.

...Nutritional assessments of swing bed patients:

The dietician is notified when the swing bed patient is admitted. The assessment is completed within 24 hrs...If the dietician is out of town..., the information nutritional sheet...is completed via phone. The dietician speaks with the RN (Registered Nurse) and signs off when she returns".

Findings include:

1. MR # 2 was admitted to the swing bed unit on 2/13/15 with a diagnosis status post fall with contusion of right hip/leg in need of Physical Therapy (PT) and Occupational Therapy (OT) services.

Review of Swing Bed MR # 2 revealed documentation that included "reason for skilled nursing admission: Rehabilitation needs for decreased endurance and mobility secondary to multiple medical/surgical issues. The treatment plan/goals of admission were "checked" Physical Therapy and Occupational Therapy, estimated stay length 3 weeks, discharge plan return home. The physician signed the document, 2/13/15, date of the swing bed admit.

A second page to the above document revealed Nursing, PT, OT, Speech Therapy, Social Services and Case Management care interventions, not completed (all areas left blank). The document was signed by the physician for the date of the swing bed admit, 2/13/15.

Further record review included a 2/13/15 initial interview and initial physical assessment, completed by the Registered Nurse (RN). PT and OT evaluations were completed 2/13/15 and 2/16/15 respectively. A one page problem activity document revealed MR # 2' routine blood glucose readings and insulin administration.

Review of the 2/15/15 Progress Note completed by the dietician included recommendation to offer a multivitamin with iron and zinc for skin healing. There was no documentation the RN notified the physician of the dietary recommendations.

There was no documentation the physician acknowledged or declined the dietician's recommendations. There was no weekly team meeting to review the dietary recommendations.

Two Case Management notes dated 2/18/15 revealed discharge plans to return home with home health services, no medical equipment needs identified. A second case management entry dated 2/25/15 for a 2/20/15 meeting with MR # 2 and caregiver to discuss discharge plans, medical equipment needs and dietary notification of food preference.

There was no evidence or documentation of an interdisciplinary team meeting including all disciplines. There was no documentation a comprehensive assessment was completed and a plan of care developed. There was no documentation weekly care plan meetings with all disciplines was conducted. Documentation in MR # 2 did not include a review of implemented interventions, progress towards goals reviewed and prioritized by the interdisciplinary team.

In an interview with Employee Identifier (EI) # 2, Director of Nursing, Swing Bed Director/Social Services and Discharge Planner on 2/25/14 at 2:50 PM, the surveyor asked for the comprehensive assessment and care plan developed on admission.

EI # 2 reported the Initial Physical Assessment is performed by the Registered Nurse and PT and OT complete their own assessments after admission. There were no weekly team and care plans meetings conducted or documented.

EI # 2 reported the above policy and procedure documents were used prior to use of the current electronic health record (EHR). The facility forms had not been revised and or incorporated into the current EHR documentation.

2. MR # 3 was admitted to the swing bed unit on 1/12/15 with a diagnosis of Weakness and Fall risk in need of PT and OT consultations.

Record review failed to include the development of a comprehensive assessment and care plan following PT, OT, Nursing, Dietary and Activity assessment completion.

A 1/23/15 Case Management note that included documentation for 1/13/15 and 1/23/15 revealed discharge plans to return home with home health, no medical equipment needs identified. A documented conversation with the caregiver revealed concern for polypharmacy, need for a bedside commode and walker and depressive symptoms. The documentation revealed "provider notified". The note was signed by EI # 2.

There were no weekly plan of care updates and interdisciplinary team meetings performed. There was no documentation all disciplines were involved in MR # 3's care planning.

3. MR # 4 was admitted to the swing bed unit on 2/9/15 with a diagnosis of Severe Weakness and Improving Dysphagia.

Record review failed to include the development of a comprehensive assessment and care plan following PT, OT, Nursing, Dietary and Activity assessment completion.

There was a Problem List included, 6 problems were identified with 5/8/12 and 5/23/12 dates. This documentation was from a previous hospital stay.

There was a Problem Activity sheet document that included all MR # 4's blood glucose values and insulin administration.

There were no weekly plan of care updates and interdisciplinary team meetings performed. There was no documentation all disciplines were involved in MR # 4's care planning.

On 2/25/15 at 2:50 PM, EI # 2 confirmed the findings.

Based on interview and review of Swing Bed records the hospital failed to assure activity assessment and plan of care was developed for the patients specific interests. This did affect Swing Bed Medical Records (MR) # 2, # 3 and # 4, 3 of 3 Swing Bed records reviewed with stays greater than 72 hours. This had the potential to affect all patients served in the swing bed unit.

Hale County Hospital
Swing Bed Policy and Procedure Manual
Subject: Swing Bed Activities

"...Policy:

An activities program shall be provided, appropriate to the needs and interest of each patient...

Procedure:

2. An Activity Assessment shall be completed within 72 business hours of admission...

4. The activities plan shall be incorporated into the patient's plan of care.
5. The plan of care shall be reviewed weekly at the patient care plan meeting...7. The plan of care shall be revised as needed to reflect patient interest and needs..."

Review of 3 of 3 Swing Bed records with admission dates greater than 72 business hours failed to include activity assessment documentation.

There was no weekly review of the plan of care. There were no revisions for individual interests and needs with patient functional progress/decline.

In a 2/25/15 2:50 PM interview with Employee Identifier # 2, Director of Nursing/Swing Bed Director, the above findings were confirmed.

This condition was cited based on review of the hospital's Quality Assessment and Improvement Plan/Program (QA IP), review of the Hale County Health Care Authority Board of Directors (otherwise known as the Board) meeting minutes and interview with the Quality Assurance (QA) Coordinator/ Director of Nursing (DON), it was determined the Governing Body (Board) failed to ensure:

1. There was an ongoing QAIP program to measure, track and analyze departmental indicators to make changes to improve patient care and outcomes.

2. Medications were securely stored and not expired.

3. Quarterly pharmaceutical and Therapeutics Committee meetings were conducted.

4. Policies were developed and implemented for the management of home medications.

Findings include:

Refer to A 263 and A 490

This condition level deficiency is written as a result of the hospital failing to maintain an ongoing quality patient care, analyze data, monitor adverse events, implement action plan to improve patient care outcomes and follow-up review to ensure quality patient care is consistently achieved. As a result of the recertification survey the areas of concern includes the following:

1. Failure to monitor and track the department's quality indicators and other aspects of hospital services and operations.
Refer to A- 273.

2. Failure to implement and document corrective actions for identified problems.
Refer to A- 283.

3. Failure to identify improvement activities and progress towards goals.
Refer to A- 297

4. Failure to identify projects and reasons for conducting these projects.
Refer to A- 308

Based on review of the hospital policy, Quality Assessment and Improvement Plan and interview with the Quality Assurance (QA) Coordinator/ Director of Nursing (DON), it was determined the facility failed to monitor and track the department's quality indicators and other aspects of hospital service and operations. This had the potential to negatively affect all patients served by the hospital.

Findings include:

Hale County Hospital Quality Assessment and Improvement Plan

Purpose

" The purpose of Quality Assessment and Improvement Program for Hale County Hospital is to establish, organize, implement, monitor and document evidence of an ongoing and systematic Quality Assessment and Improvement Process that includes effective mechanisms for reviewing and evaluation the care provided to patients including all age groups to ensure one level of care.

Objectives

1. Implementing a planned, systematic and ongoing process for monitoring, evaluating and improving the quality and appropriateness of care provided to patients.
...
4. Designing an evaluation process that will determine the presence or absence of an opportunity to improve on a problem, in the quality and/ or appropriateness of care.

5. Determining how problems can be corrected and whether care can be improved.
...
9. Overseeing and evaluating the effectiveness of quality assessment and improvement activities and modify as necessary to better monitor care provided to patients.

10. Continue educational process and implement continuous quality improvement."

Review of the Quality Assessment and Improvement Plan conducted on 2/25/15 at 3:15 PM with Employee Identifier (EI) # 2, QA Coordinator/ DON revealed all department submits a quality review to the QA Coordinator/ DON monthly the surveyor asked what was the next step after gathering all the data submitted, the QA Coordinator/ DON stated that she/ he just gathers data and places it in a 3 ring binder.

An interview was conducted on 2/25/15 at 3:15 PM with Employ EI # 2, who confirmed the above mentioned findings.

Based on review of the hospital policy, Quality Assessment and Improvement Plan departmental audits and interview with the Quality Assurance (QA) Coordinator/ Director of Nursing (DON), it was determined the hospital failed to implement corrective actions focusing on performance improvement, ensure actions taken have a positive affect on patient outcomes, safety and quality of care. This had the potential to negatively affect all patients served by the hospital.

Findings include:

Hale County Hospital Quality Assessment and Improvement Plan
...

Communications

" The results of the monitoring and evaluation process are communicated to relevant individuals, departments, or services and to the organization wide Quality Assessment and Improvement Program."

Review of the Quality Assessment and Improvement Plan on 2/25/15 revealed no documentation of corrective actions implemented.

An interview was conducted on 2/25/15 at 3:15 PM with Employee Indentifer (EI) # 2, QA Coordinator/ DON who confirmed the above mentioned findings.

Based on review of the hospital policy, Quality Assessment and Improvement Plan and interview with the Quality Assurance (QA) Coordinator/ Director of Nursing (DON) it was determined the facility failed to document reasons for conducting identified projects and progress to goals achieved. This had the potential to negatively affect all patients served by the hospital.

Findings include:

Hale County Hospital Quality Assessment and Improvement Plan

Clinical Indicators

" In order to assess structure, process or outcome, clinical indicators which are well defined, measurable and based on major aspects of care will be developed for the purpose of identifying trends or patterns of care that may not be evident when only case-by-case review is performed.

Evaluation

When pre-established thresholds are reached, care will be evaluated to identify patterns of performance, or opportunities to improve patient care. Evaluation will include causative analysis from which conclusions will be made. ..

Actions

When problems or opportunities to improve patient care are identified, appropriate corrective action plans will be developed and implemented.

Assessment

Problems, trends or opportunities to improve patient care will be re-evaluated to determine the effectiveness of action taken. Periodic follow-up will continue until significant resolution/ improvement is documented."

Review of the Quality Assessment and Improvement Plan audits January to December 2014 revealed no documentation of actions taken to correct identified problems/ projects.

An interview was conducted on 2/25/15 at 3:15 PM with Employee Identifier (EI) # 2, QA Coordinator/ DON who confirmed the above mentioned findings.

Based on the review of the hospital Quality Assessment and Improvement Plan (QA IP), review of the minutes of the Hale County Heath Care Authority, Board of Directors (Otherwise known as the Board) meeting and interview with the Quality Assurance (QA) Coordinator/ Director of Nursing (DON) it was determined the facility failed to ensure the QA IP is actively meeting and discussing issues identified by each department. This had the potential to affect all patients served by this facility.

Findings include:

During the interview with the Employee Identifier (EI) # 2, QA Coordinator/ DON conducted 2/25/15 at 3:15 PM the surveyor asked how often the members of the QA Team and she/ he stated the committee did not meet year 2014 and had not met since she/ he became the QA Coordinator.

Review of the Board meeting minutes for 2014 revealed the following:

February 28,2014- Board met, there was no documentation of QA IP activities or findings.

April 22,2014 - Board met, there was no documentation of QA IP activities or findings.

May 2014 - No meeting

June 9, 2014 - Board met, there was no documentation of QA IP activities or findings.

July 1, 2014 - Board met, there was no documentation of QA IP activities or findings.

July 29, 2014 - Board met, there was no documentation of QA IP activities or findings.

August 26, 2014 - Board met, there was no documentation of QA IP activities or findings.

September 2014 - No meeting

October 2014 - No meeting

November 18, 2014 - Board met, there was no documentation of QA IP activities or findings.

December 2014 - No meeting.

Hale County Hospital Quality Assessment and Improvement Plan

Board of Directors

" The Board of Directors shall maintain ultimate responsibility for the Quality Assessment and Improvement Program, striving to assure quality patient care by requiring and supporting the establishment and maintenance of an effective hospital wide quality assessment and improvement program.

The Board delegates the authority to perform this function to the Medical Staff through the Medical Executive Committee and Administrator, but the Board will:

- receive and review periodic reports of findings, actions, and results of actions from the Quality Assessment and Improvement Program;

- approves the QA IP which includes an assessment of the program's efficiency and effectiveness on an annual basis;

- recommend appropriate organizational and/ or activity modification;

- assure that the primary goal of patient care enhancement is achieved."

An interview was conducted on 2/25/15 at 3:15 PM with EI # 2, who verified the above mentioned findings.

Based on review of medical records, policy and procedures, Alabama Board of Nursing Standards of Practice and interviews it was determined the nursing staff failed to:

1. Document specific wound care provided

2. Document wound assessments to include appearance of the wound/ wound bed, exudates, drainage, odor signs and symptoms of infection' skin surrounding the wound and measurement.

3. Document the skin surrounding the wound

4. Document education to caregiver or patient related to wound care after discharge.

5. Document weights as ordered.

6. Administer medications as ordered.

8. Ensure staff monitored the nurse unit crash cart and defibrillator per policy.

This had the potential to affect all patients served by the facility and did affect 7 of 12 Medical Records (MR) including MR # 1, # 6 # 7 and # 9, and Swing Bed MR's # 2, # 3, and # 4.

Findings include:

Hale County Hospital (HCH) Policy Wound (Decubiti) Assessment and Documentation

Written: 06/09/10

The following is the policy and procedure for the proper documentation of assessment for patients that have wound (decubiti).

Responsibility for completion of Wound Assessment Form:
...
2. " The wound assessment form must be completed each day, once per day, by the licensed nurse performing the wound treatment.

The wound assessment form is otherwise self explanatory for what other information should be included. See Attached Wound Assessment Form.

The Wound Assessment Form is yellow in color."

HCH Wound Assessment Form
...

" Description of Treatment for Ulcer __________...
...

Date Time Nurse Signature of Treatment Complete."


Alabama Board of Nursing Chapter 610-X-6
Standards of Nursing Practice

610-x-6-.13 Standards for Wound Assessment and Care

(1)" It is within the scope of a registered nurse or licensed practical nurse practice to perform wound assessments including, but not limited to, staging of a wound and making determinations as to whether wounds are present on admission to a healthcare facility pursuant to an approved standardized procedure..."

(2) " The minimum training for the registered nurse or licensed practical nurse that performs selected tasks associated with wound assessment and care shall include:
(a) Anatomy, physiology and pathophysiology.
(c) Equipment and procedures used in wound assessment and care.
(d) Chronic wound differentiation.
(e) Risk identification.
(f) Measurement of wound.
(g) Stage of wound.
(h) Condition of the wound bed including:
(i) Tissues
(ii) Exudates
(iii) Edges
(iv) Infection
(i) Skin surrounding the wound."

610-X-6-.06 Documentation Standards

(1)" The standards of documentation of nursing care provided to patients by registered nurses or licensed practical nurses are based on principles of documentation regardless of the documentation format.

(2) Documentation of nursing care shall be:
(a) Legible
(b) Accurate
(c) Complete. Complete documentation includes reporting and documenting on appropriate records a patient's status, including signs and symptoms, response, treatments, medications, other nursing care rendered, communication of pertinent information to other health team members, and unusual occurrences involving the patient."

1. MR # 6 was admitted to the hospital on 9/27/14 with the diagnoses including Urinary Tract Infection, Open Wound Right Leg and Chronic Stage IV on Coccyx and Bilateral Hips.

The Physician Entered Order 9/27/14 written by Employee Identifier (E) # 10, Certified Registered Nurse Practitioner (CRNP) for daily weights and wound care to right lower leg, clean wound with peroxide/ saline then apply Bactroban dress with 4x4 gauze 2 times a day.

Review of the Registered Nurse (RN) notes 9/28/14, 9/29/14, 9/30/14, 10/1/14 and 10/2/14 revealed there was no documentation wound care was provided, the wound was measured and assessed.

Further review of the RN notes dated 9/28/14, 9/29/14, 9/30/14, 10/1/14 and 10/2/14 revealed documentation the daily weights were not taken as ordered.

An interview was conducted on 2/26/15 at 9:15 AM with Employee Identifier (EI) # 2, Director of Nursing (DON) who confirmed the above mentioned findings.

2. MR # 7 was admitted to the hospital on 2/3/15 with the diagnoses including Open Wound Hip, Degenerative Joint Disease, Knees, Hypertension and Status Post Colostomy.

Physician Entered Orders 2/3/15 written by EI # 10 had the following wound orders: "wet to dry dressing to coccyx 2 times a day, pack left hip with saline soaked 2 inch kling 2 times a day and Maxorb Extra wet with saline then pack with 2 inch kling to left hip every morning."

Review of the RN note 2/5/14 revealed documentation the left hip wound care was cleaned with saline and Betadine- size 4x4, packed with Microderm and wet to dry dressing applied. There was no physician order for the wound care performed.

Physician Entered Orders 2/6/15 written by EI # 10 for wound care was revised to: "Dakin's Solution dressing to wound bed left hip 2 times a day apply Dakin's solution to wound bed. Don't get any on the good tissue."


Review of the RN notes dated 2/4/15, 2/5/15, 2/6/15, 2/7/15, 2/8/15 and 2/9/15 revealed there was no documentation wound care was provided as ordered.

An interview was conducted on 2/28/15 at 9: 30 AM with EI # 2 who confirmed the above mentioned findings.




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3. Swing Bed MR # 2 was admitted to the unit on 2/13/15 with a diagnosis status post fall with contusion of right hip/leg.

Record review revealed the patient was a Type II Diabetic, requiring insulin per sliding scale. Review of the 2/19/15 7:00 AM nurse problem activity document and medication record document revealed a blood glucose of 175, Intervention: Not given. 2 units of Novolin R (regular) insulin was ordered. The two documents revealed insulin was not administered.

A written inquiry, presented to EI # 1, Chief Executive Officer (CEO)/Administrator on 2/25/15 at 4:00 PM and received on 2/26/15 at 10:40 AM confirmed insulin was not administered as ordered.

4. Swing Bed MR # 3 was admitted to the unit on 1/12/15 with a diagnosis of Weakness and Fall risk.

Review of the Swing Bed Service document, signed by the patient included weights will be taken once a week unless specified by the physician.

The 1/12/15 admitting weight was 178 lbs (pounds). The next weight documented was 1/26/15, 162.2 lbs. There was no weight documented for the week of 1/16/15.

Record review revealed 1/14/15 nurse documentation the patient had a skin tear to the left forearm. The nurse documented, dressing changed to skin tear to left arm. Cleaned with NS (normal saline) and applied Polysporin ointment 4 x 4 gauze and secured with paper tape.

Record review revealed on 1/15/15 the nurse documented neosporin and 4 x 4 (gauze) dressing applied to left FA (forearm).

There was no physician's order for the wound care performed. There were no wound assessments documented that included the left forearm skin tear size, wound observations including the presence of drainage, pain and appearance of surrounding skin.

A written inquiry, presented to EI # 1 on 2/25/15 at 4:00 PM, received on 2/26/15 at 10:40 AM confirmed the aforementioned findings.

5. Swing Bed MR # 4 was admitted to the unit on 2/9/15 with a diagnosis of Severe Weakness, Improving Dysphagia and Diabetes Mellitus, Type II.

Review of the Swing Bed Service document, signed by the patient included weights will be taken once a week unless specified by the physician.

The 2/9/15 admitting weight was 240 lbs. The next weight documented was 2/22/15, 238 lbs. There was no weight documented for the week of 2/16/15.

Record review revealed MR # 4 required Novolin R (regular) insulin per 2/17/15 sliding scale order. Review of the 2/19/15 6:59 AM Diabetic Flowsheet and medication record documentation revealed a blood glucose of 163, Intervention: 2 units of Novolin R (regular) insulin (for blood glucose 150-199), "Not given". The nurse documentation revealed the sliding scale insulin was not administered as ordered.

6. MR # 1 was admitted to the medical unit 2/17/15 with diagnoses including Acute Cellulitis to the Lower Extremities and Diabetes Mellitus

This condition of participation for Pharmaceutical Services is out of compliance based on observation, review of Quarterly Pharmacy and Therapeutics Committee meeting minutes, review of policy and procedures and review of Medication Administration records.

The facility failed to:

1. Store medications, keep the controlled medications secured and manage medications according to policy. Refer to A 500 and A 503

2. Conduct Quarterly Pharmacy and Therapeutics Committee meetings. Refer to A 492

3. Develop and implement a policy for home medication management. Refer to A 500.

4. Ensure all medications and biological's available for patients were not expired. Refer to A 505

This had the potential to affect all patient served by the facility.

Findings include:

Refer to A 492, A 500, A 503 and A 505 for findings.

Based on review of facility policy and procedures, Pharmacy Consulting Pharmacist Monthly Report and staff interviews, it was determined the facility failed to conduct Pharmacy and Therapeutic (P&T) committee meetings.

Findings include:

Subject: Pharmacy and Therapeutic Committee
Revised: 11/98

" It is the policy of Hale Country hospital to address pharmacy and therapeutic issues at monthly Medical Staff meeting and Nursing Service meetings..."

Policy: Meetings
Written: June 2005

" Infection Control, Pharmacy...meetings will be held in conjunction with monthly Medical Staff, Departmental Meetings..."

Findings include:

Review of the Hale County Hospital Department of Pharmacy Consulting Pharmacist monthly reports for 2014 did not include development, coordination and/or participation in Pharmacy and Therapeutic meetings.

During a 2/25/15 1:45 PM phone interview with Employee Identifier (EI) # 3, Consulting Pharmacist, reported the facility did not have documentation of minutes of committee meetings with facility staff regarding pharmaceutical services.

In an 2/25/15 2:20 PM interview with EI # 1, Chief Executive Officer/ Administrator confirmed the facility failed to conduct P&T meetings.

Based on review of facility policy and procedure, observations and staff interview, it was determined the facility failed to:

a) Ensure refrigerator temperatures were within acceptable ranges for medication storage.

b) Develop and implement a policy for home medication verification.

This had the potential to affect all patients served by the facility.

Findings include:

Facility Document
Title: "Temperature Regulation of Refrigerator...

Temperatures shall be recorded and kept on file of (for) all refrigerators...A thermometer should be located in each refrigerator...and recorded...Refrigerator...temperatures shall be within the acceptable range of 34 to 40 Degrees (Fahrenheit)...At any time any refrigerator...is not within the acceptable range, it must be reported to Plant Operations immediately."


During a 2/24/15 11:34 AM tour of the nursing department, a refrigerator in the Clean Utility room was found to have the following stored in it:

1. A metal box with a pad lock on it with Eighteen injectable Ativan 2 milligram (mg)/milliliter vials.
2. Nine open insulin vials.

The refrigerator had a Monthly Temperature Range Chart, dated October 1 to 9, 2013 taped to the door.

The surveyor asked Employee Identifier (EI) # 6, Registered Nurse, Charge Nurse, if the refrigerator temperature was being monitored. EI # 6 reported staff had not monitored the refrigerator temperature.

The facility was unable to determine that Ativan and insulin which required refrigeration were kept within an acceptable temperature range.

In a 2/25/15 1:30 PM interview with EI # 1, Chief Executive Officer, Hospital Administrator, the finding was confirmed.

2. During a medication pass observation on 2/25/15 at 8:45 AM with the Licensed Practical Nurse, EI # 8, Metformin 850 mg was administered from a patients home prescription bottle.

During observations of medication management on the nursing unit and interview with EI # 6 on 2/25/15 at 10:30 AM, EI # 6 was asked how patient home prescription medications are verified as accurate before dosing. EI # 6 reported use of a written description of the medication on the prescription bottle (if available), a nursing drug reference or the PDR (physician's desk reference) is used.

In an interview on 2/25/15 at 1:45 PM with EI # 1 confirmed the facility did not have a policy for home medication verification. EI # 1 reported staff can also use the Internet to verify patient home medications.

Based on review of facility policy and procedure, observation and staff interviews, it was determined the facility failed to secure storage of controlled drugs. This had the potential to affect all patients served by the facility.

Findings include:

Subject: Controlled Substances
Revised: 11/97

Policy

"Narcotics, barbiturates, and other controlled substances must be handled and secured in accordance with Federal and State requirements.
They must be kept under double lock at all times..."


During a 2/24/15 11:34 AM tour of the nursing department, a refrigerator in the Clean Utility room was found to have a metal box with a pad lock on it.

The surveyor asked EI # 6, Registered Nurse, Charge Nurse, what was in the metal locked box. The box was opened at request of the surveyor. Eighteen injectable Ativan 2 milligrams/milliliter vials (controlled substance schedule IV) were in the unlocked refrigerator in the unlocked Clean Utility room.

The facility failed to ensure controlled drugs were secured as per policy under double lock at all times.

In a 2/25/15 1:30 PM interview with EI # 1, Chief Executive Officer/ Hospital Administrator, the finding was confirmed.

Based on review of policy and procedure, observations and interview, it was determined the facility failed to ensure:

a) all biologicals in patient treatment areas were not expired.

b) all biologicals in use were correctly labeled.

This had the potential to negatively affect patients receiving care from surgery services.

Findings include:

Nursing Service
Subject: Out-Of-Date-Drugs
Revised:11/97

Policy:

"Drugs throughout the hospital are inspected monthly by the Consulting Pharmacist and/or his designee..for out- of- date drugs. Drugs that are outdated or that will expire before the next inspection are pulled and placed in a container marked Caution: OUTDATED DRUGS-DO NOT USE..."


Centers for Disease Control and Prevention

4. "When should multi-dose vials be discarded?

Medication vials should always be discarded whenever sterility is compromised or questionable.
In addition, the United States Pharmacopeia (USP) General Chapter 797 [16] recommends the following for multi-dose vials of sterile pharmaceuticals:
If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial."


1. During the tour of the Emergency Department (ED) Medication Room on 2/25/15 with the Employee Identifier (EI) # 9, Licensed Practical Nurse (LPN), the following medications were found dated greater than 28 days.

1. Labetalol Hydrochlorothiazide 1 gram injectable labeled opened 11/2014.

An interview was conducted on 2/25/15 at 10:45 AM with EI # 2 who confirmed the above mentioned findings.


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2. During a tour of the nurse unit on 2/24/15 at 10:55 AM, 9 sterile culture collection and transport system swabs, expired 9/2014 were found in the nurse office on the nursing unit.

3. On 2/24/15 at 11:34 AM in the nursing department, a refrigerator in the Clean Utility room was found to have the following outdated medications:
One 0.9 % Sodium Chloride 10 milliliter (ml) syringe expired 11/2011
Eight Phenadoz 12.5 milligram (mg) rectal suppositories, expired 4/2013

On the storage shelf in the Clean Utility room, one quart bottle of Similiac Sensitive infant formula, expired 12/1/14 was found.

4. During observations on the nurse unit and interview with EI # 6 on 2/25/15 at 10:30 AM, the following medications were found on the nurse medication cart and not labeled for use:
1 bottle CQO 10 200 milligrams (mg), 1 tablet
1 bottle Divalproex Sodium 125 mg, 2 tablets
Fluticasone Proponate 50 microgram, 1 inhaler

The following medications were found in the patient medication cart, reported by EI # 6 to belong to discharged patients (prescription labels were on the medication bottles):
Cyclobenzaprine 10 mg 1 by mouth at bedtime
Tramadol Hydrochloride 50 mg 1-2 as needed for pain

The following labeled medications were found in the locked medication cabinet at the nursing station. The medications were reported to be discharged patients medications left at the facility per EI # 6:
Magnesium Oxide 400 mg 1 tablet daily
Sertraline Hydrochloride 100 mg 1 1/2 tablets by mouth daily.

In an interview on 2/25/15 at 11:00 AM with EI # 6, Registered Nurse, Charge Nurse confirmed there were unlabeled medications and discharged patient home medications on the patient medication cart. Home medications had not been removed from the nursing unit after the patients were discharged. There were expired biologicals and medications not removed from the nursing unit.

Based on observations, CDC (Centers for Disease Control ) guidelines for hand hygiene in health care settings, facility policy for hand hygiene and EvenCare Glucometer use and interviews, it was determined the staff failed to:

1. Perform hand hygiene per facility policy and CDC guidelines .

2. Maintain and clean equipment to prevent potential infection to patients and/or staff by use.

This had the potential to affect all patients served by this facility and staff.

Findings include:

www.cdc.gov
Morbidity and Mortality Weekly Report
Recommendations and Reports October 25, 2002 / Vol. 51 / No. RR-16
Centers for Disease Control and Prevention

Guideline for Hand Hygiene in Health-Care Settings
Recommendations for Hand Hygiene

" 1...
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, lifting a patient)
I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient
J. Decontaminate hands after removing gloves..."

2. Hand-hygiene technique...
B. When washing hands with soap and water...Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet (IB) (90-92,94,411)..."

Facility Document
Subject: Handwashing

Handwashing is the single most effective deterrent to the spread of infection

Policy

Hospital personnel shall wash their hands to prevent the spread of infections:

"...2. Before applying and after removing gloves...
4. Between handling of individual patients...

Procedure:
...5. Dry hands well with paper towels, then use the paper towel to turn off faucet..."


Centers for Disease Control and Prevention
January 4, 2012
"Infection Prevention during Blood Glucose Monitoring and Insulin Administration

·FAQs: Blood Glucose Monitoring and Insulin Administration ..........

The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration.

CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements:.....Fingerstick devices should never be used for more than one person. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared.... "

Facility Document

EvenCare G2 Blood Glucose

Intended Use:
"The EvenCare G2 Blood Glucose Monitoring System is intended...for both lay use...and in a clinical setting by healthcare professionals..."

1. During an observation of care on 2/25/15 at 8:05 AM with Occupational Therapist, Employee Identifier (EI) #4, completed the therapy session, went to the sink in the patient's room, performed hand hygiene and turned off the faucet with clean hands.

EI # 4 did not turn off the faucet with a paper towel.

In an interview on 2/26/15 at 12:30 PM with EI #1, Chief Executive Officer/Administrator confirmed staff did not follow the facility policy for hand hygiene.

2. On 2/24/15 at 11:20 AM the surveyor observed EI #5, Laboratory Department Manager check the blood glucose for 2 unsampled patients using an EvenCare glucometer. EI # 5 donned gloves upon entry into the patient's room, performed the blood glucose test and exited the patient room wearing gloves used during the blood glucose testing.

EI # 5 did not perform hand hygiene prior to donning gloves. EI # 5 did not clean the EvenCare glucose monitor after checking the first patient's blood glucose. EI # 5 did not wash his/her hands after completing blood glucose testing and after glove removal.

EI # 5 removed and discarded his/her gloves after entering the second patient's room.

EI #5 did not clean the glucose monitor after patient use.

EI # 5 performed the blood glucose test for the next patient using the Even Care glucose monitor. EI # 5 removed his/her gloves and and placed the gloves in the trash in the patient's room. EI # 5 did not perform hand hygiene after glove removal and before donning clean gloves.

EI # 5 exited the patient room to nursing station counter. EI # 5 documented the blood glucose results in the manual at the nursing station.

EI # 5 did not clean the EvenCare Blood Glucose monitor according to CDC guidelines after patient use. EI # 5 did not follow CDC guidelines for hand hygiene.

An interview conducted on 2/25/15 at 8:20 AM with EI # 5, confirmed the EvenCare blood glucose monitor was not cleaned between patient use and hand hygiene was not performed per CDC requirements and facility policy.