HospitalInspections.org

Based on review of 3 medical records and interview during tour of the nursing floor on 1/20/15, it was determined that the facility failed to inform the patient of his/her rights prior to furnishing patient care to 1 of 3 patients.
Findings were:
Patient # 2 was admitted to the hospital on 1/15/15. Review of the medical record of Patient # 2 on 1/20/15 revealed no signed (by patient or representative) Patient Rights form.
In an interview with the Director of Nurses on 1/20/15, the unsigned Consent to Treatment form was confirmed.

Based on review of 3 medical records and interview during tour of the nursing floor on 1/20/15, it was determined that the facility failed to receive informed consent for treatment from 1 of 3 patients.
Findings were:
Medical Staff By-Laws stated in part under RR.3 Consent to Care "A general consent form, signed by or in behalf of every patient admitted to the hospital, must be obtained at the time of admission. The admitting office should notify the attending practitioner whenever such consent has not been obtained. When so notified, it shall, except in emergency situations, be the practitioner's obligation to obtain proper consent before the patient is treated in the hospital."
Patient # 2 was admitted to the hospital on 1/15/15. Review of the medical record of Patient # 2 on 1/20/15 revealed no signed (by patient or representative) Consent to Treatment form.
In an interview with the Director of Nurses on 1/20/15, the unsigned Consent to Treatment form was confirmed.

Based on review of documentation and interview, it was determined that the facility failed to measure, analyze and track quality indicators that assess hospital services in its Quality Assessment and Performance Improvement program during the calendar year of 2014.

Findings were:

Facility policy entitled "Quality Assurance Plan" stated in part "Agency objective is to provide high quality skilled nursing, home health aide, physical therapy, occupational therapy, speech therapy, and medical social worker services. We will provide an on-going monitoring and evaluation of patient care in a systematic manner. Action will be initiated for change when monitoring and evaluation identify areas for improvement. Further follow up will evaluate the action taken and its effectiveness until resolution of the problem is accomplished."

Review of Quality Assessment and Performance Improvement meeting minutes for the year 2014 revealed no documented tracking of medical errors or adverse events. Further, in problems that were identified, there was no documented evidence of root cause analysis, implementation of preventative actions or of feedback and learning opportunities for hospital staff.

In an interview with the Director of Nurses on 1/20/15, the lack of documented evidence in Quality Assessment and Performance Improvement meeting minutes of root cause analysis, implementation of preventative actions or of feedback and learning opportunities for hospital staff was confirmed.

Based on observation and interview, it was determined that the facility did not ensure outdated medications were not available for patient use.

Findings were:

Tour of the Operating Room and inspection of the Malignant Hypothermia box on 1/20/15 revealed the following:

? 6 vials of Dantrolene with an expiration date of September 2014
? 2 boxes of Sodium Bicarb with an expiration date of October 2014

In an interview with the Director of Nurses on 1/20/15, the above expired supplies were confirmed.

Based on observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for its staff and patients.

Findings were:

"OSHA/Blood Borne Pathogen Regulations Policy #138-030-060" stated in part "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."

Facility policy entitled "Infection Control" stated in part "Anson General Hospital shall provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There shall be an active program from the prevention, control and surveillance of infections and communicable disease."

Facility policy from "Housekeeping Policy and Procedure Manuel" stated in part "All soil and dust shall be removed from surfaces with a clean cloth and hospital grade disinfectant registered by the Federal EPA. These surfaces include horizontal surfaces, especially bed frames over bed lights, over-the-bed tables, bedside tables, furniture and window sills ...All air conditioner vents in the hospital will be inspected and cleaned on Mondays. Special attention will be paid to patient care areas and meal preparation and serving areas."

Dietary policy entitled "Handling Ice" stated in part "Employees will wear gloves and use the scoop provided to dispense ice. The ice scoop will be stored in a container for that purpose and handle will not be allowed to come into contact with ice in the machine."

The Centers for Disease Control and Prevention (CDC) article entitled, "Guidelines for Environmental Infection Control in Health-Care Facilities, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee" (2003), found at: , states, "Do not store the ice scoop in the ice bin." in the section entitled, "IX. Ice Machines and Ice."

Tour of the Emergency Department on 1/20/15 revealed the following:
? High horizontal dust throughout. The blowing of dust could contaminate clean surfaces.
? Stained floor tiles in the patient restroom and the trauma rooms indicating improper maintenance of the area.
? Chipped laminate surfaces on countertops. Chipped and peeling surfaces make thorough cleaning impossible and cross contamination likely.
? Molding pulling away from walls-indicating moisture damage.
? Vinyl tears on the arm of a chair sitting in Trauma Room # 2. These tears make sanitation impossible and cross contamination likely.

Tour of the Radiology Area on 1/20/15 revealed the following:

? A pitted and cracked cement floor which created a trip hazard for radiology staff.
? A wheelchair used for transporting patients was noted to have an eight inch tear in the seat. This tear does not allow for thorough cleaning and could cause cross contamination.
? Sagging and stained ceiling tiles which indicated a water leak in the area.

Tour of the kitchen on 1/20/15 revealed the following:

? An ice scoop was found stored in the ice (although there was a sign on the front of the ice machine prohibiting this practice.)
? Dirty ceiling vents directly over the dishwasher which could spread dust onto clean surfaces.
? 2 fluorescent light fixtures with copious amounts of dead bugs inside were found in the dishwashing room. These dead bugs indicated improper cleaning of the area.
? Corroded and rusted metal door frames which made cleaning of the area impossible.
? Dusty vent hood and pipes that were suspended over cooking and food preparation areas. This dust could contaminate patient food.
? The "Monthly Cleaning Schedule" was found hanging in the kitchen. It stated a list of items to be cleaned daily, weekly and monthly with areas to initial when the tasks had been completed. The schedule for January 2015 was mostly blank; indicating that scheduled cleaning had not been completed.

Tour of the Physical Therapy Department on 1/20/15 revealed the following:

? A torn and stained carpet covering the treatment floor. This rug had what appeared to be sawdust spilled in various spots. When asked how often housekeeping attended to this area, Staff member # 4 (Physical Therapy Technician) stated "I vacuum every day."
? A Weider Pro 9940 (weight machine) had a tear on its vinyl arm rest which made cleaning impossible and cross contamination likely.
? A pillow was found on a treatment table which had a torn covering, again making a cross contamination risk.

Tour of the Nursing floor on 1/20/15 revealed the following:

? Dust on high horizontal surfaces which indicated improper cleaning of the area.
? A heavy urine odor in the "clean" bathroom connected to unoccupied patient room # 131

Tour of the Operating Room on 1/20/15 revealed the following:

? Dust and rust on the base of the operating table. The condition of the OR table made cleaning impossible and cross contamination likely.

In interviews with the Director of Nurses and the Hospital Administrator on 1/20/15, the above findings were confirmed.

Based on review of 3 medical records of swing bed patients on 1/20/15, it was determined that the facility failed to provide a psychosocial assessment to 1 of 3 patients.
Findings were:
Review of the medical record of Patient # 3 (swing bed/admitted 1/14/15) revealed no psychosocial assessment as of 1/20/15.
In an interview with the Director of Nurses on 1/20/15, the lack of a psychosocial assessment was acknowledged. She stated, "Our Social Worker quit last month. We have postings in all the newspapers."