HospitalInspections.org

Based on review of the facility Plan of Correction (POC) approved on 2/4/16 by the Centers for Medicare and Medicaid Services, (CMS), facility policies and procedures, observations, facility safety round documentation, seclusion/restraint logs, observation logs, manufacturers directions for use, infection prevention tracking report, the Quality Assurance and Improvement Plan and interviews, it was determined the Governing Body failed ensure:

1) the facility CMS POC dated 2/8/16 was implemented as approved.

2) environmental hazards were removed from the Gateway Behavioral Health Unit (BHU), environmental safety rounds were completed and documented and concerns identified on environmental safety rounds had been repaired.

3) staff followed the facility policy and procedure for use of seclusion.

4.) the facility staff developed and utilized a Quality Improvement Plan to include problem solving, assessed the effectiveness of action taken to improve patient care and safety.

5) the effectiveness of the Quality Assurance and Performance Improvement Program monitored by the Governing Body.

6) wound care was performed as ordered and wounds were measured per facility policy.

7) all medications were administered as ordered by the physician.

8) staff documented the anatomical location for intramuscular (IM) medication administration and evaluated the therapeutic effectiveness of prn (as needed) medications.

9) staff provided group therapy as documented in the patient treatment plan and physician participation/ approval in development of the Treatment Plan was documented.

10) staff observations documented on the Observation Log were completed after actual patient observations.

11) patient's history and physical (H&P) was completed within 24 hours after admission per policy.

12) hospital staff completed medical records completed within 30 days following discharge.

13) measures were taken to identify, prevent, and minimize diversion of medications and medication errors.

14) patients received the amount of medications ordered.

15) medications were stored, dispensed and managed according to the facility policy

16) all medications available for patient use were not expired.

17) preventive maintenance inspection on all equipment in the Radiology Department was performed.

18) radiation badges were monitored according to facility policy.

19) facility was constructed, arranged and maintained to ensure patient safety.

20) staff followed proper hand hygiene per policy.

21) all patient rooms were cleaned and disinfected with products effective against Clostridium Difficile (C Diff).

22) the monthly infection prevention tracking report included results of all gastrointestinal cultures positive for Clostridium Difficile.

23) all patients referred to a Home Health agency were given the patients a choice of providers.


Refer to A 0144, 0167, 0273, 0286, 0297, 0308, 0309, 0392, 0396, 0458, 0468, 0469, 0491, 0494, 0500, 0502, 0503, 0505, 0508, 0537, 0538, 0700, 0749 and 0823 for additional findings.

Based on review of the facility Plan of Correction (POC) approved on 2/4/16 by the Centers for Medicare and Medicaid Services, (CMS), facility policy and procedure, observations, facility round documentation and interviews, it was determined the staff failed to assure all patients were kept safe and:

1) all environmental hazards were removed from the Gateway Behavioral Health Unit (BHU).

2) all environmental safety rounds were completed and documented according to facility policy.

3) all concerns identified on environmental safety rounds had been repaired.

4) the facility CMS POC dated 2/8/16 was implemented as approved.

Findings include:

Bullock County Hospital
Policies and Procedures effective date 1/25/2016
Manual: Gateway

Title: Unit Safety Checks

" Policy: The Charge RN (Registered Nurse) or Designee at the beginning of each shift will inspect the entire unit for properly locking doors, adequate lighting, contraband, etc. Any problems will be noted and reported as soon as possible to the appropriate individual.

Procedure:
A. The oncoming Charge RN of Designee and the off going Charge RN or designee will walk the entire unit at before or after the start of the shift.
B. Inspection will include all areas of the unit.
C. Any contraband, to include but not limited to: sharps, cans, wire hangers, lighter, cords, bottles, personal items...will be removed immediately, labeled and put in the patient lockers and noted.
D. Any other deficiencies, such as: housekeeping issues, maintenance problems...must also be noted."

During a tour of the Gateway BHU on 9/12/17 at 11:00 AM with Employee Identifier (EI) # 1, Chief Nursing Officer (CNO), the surveyor observed the following:

Patient room 105 with exposed sheetrock and peeling paint next to window.

Patient room 106 with exposed sheetrock and peeling paint.

Patient room 107 vinyl baseboard was separated from the wall.

A retractable shower curtain rod over the bathtub in the common bathroom on the adult unit.

In the adult TV (television) room, the shatterproof window glass (lexan pane) had a large crack, such that the surveyor was able to insert her finger through to the outside. There were 6 metal hooks attached with screws hanging on top of the windows in the adult television room.

Review of the 9/12/17, 7:52 AM Environmental Safety Round documentation failed to identify the findings in patient rooms 105, 106, 107 and adult TV room.

Review of September 5, 2017 Environmental Safety Round documentation revealed the vinyl baseboard in room 107 was separated from the wall. The surveyor observed the identical finding 7 days later on 9/12/17 at 11:10 AM. There was no documentation staff had completed a work order for the baseboard repair. The facility staff failed to ensure all vinyl baseboards were secured to the wall.

Review of the facility August and September 2107 Environmental Safety Round documentation failed to reveal staff completed safety rounds on 8/5/17, 8/6/17, 8/19/17, 8/20/17, 9/2/17, 9/3/17, 9/9/17 and 9/10/17.

****

On 9/12/17 at 11:10 AM, the surveyor asked the Lead Mental Health Technician, Employee Identifier (EI) # 11 to demonstrate how the pressure sensors located on patient room and bathroom doors worked. EI # 1, Chief Nursing Officer verbalized all patient door pressure sensors were "disabled". The surveyor asked EI # 1 when the sensors were disabled and why? EI # 1 reported she/he was not sure.

During an interview on 9/13/17 at 8:00 AM in the nurses station of the BHU with Psychiatric Registered Nurse, EI # 13, the surveyor asked how long she/he had worked at the BHU? EI # 13 reported since February 2017. The surveyor then asked if he/she was aware the patient room/bathroom door pressure sensors were disabled? EI # 13 reported yes, they had worked in the past but he/she did not know when they were disabled.

In an interview on 9/13/17 at 3:15 PM, EI # 12, Psychiatrist, BHU Medical Director, reported he/she was not sure how long the pressure sensors on the patient room and bathroom doors had been disabled, maybe a few days or a week.

During an interview on 9/14/17 at 9:30 AM, EI # 2, Administrator reported the pressure sensor door alarm installation was part of the facility plan of correction following a patient suicide by hanging.

EI # 2 verified the facility reimbursed the company who installed the door sensors in May 2016. EI # 2 confirmed additional visits to the facility had been completed, however the pressure sensors never worked.

EI # 2 reported the pressure sensor installation was unsuccessful and the patient door and bathroom door sensors were never functional.

Review of the CMS 2567 Statement of Deficiency dated 1/7/16 followed an onsite complaint survey. The onsite survey was completed after a successful patient suicide (by hanging). The facility plan of correction approved on 2/8/16 revealed the following:

A 043 Governing Body

1. Safe environment on the Gateway Unit.

...Over-the-door pressure sensors alarms that will be installed....

Review of the facility Governing Body minutes dated 2/8/16 revealed the over-door-pressure sensor alarms would be done in one year. No 2017 Governing Body minutes were submitted to the state surveyor.

During the onsite recertification survey on 9/14/17, the surveyor determined the facility had not implemented the over-door-pressure sensor alarms.

There was no documentation the state agency was notified the facility had not successfully implemented all aspects of the POC.

In an interview on 9/14/17 at 1:30 PM, EI # 2, confirmed the above findings.

Based on review of facility policy and procedure, medical records and interview, it was determined the staff failed to follow the policy and procedure for use of seclusion. This affected Medical Record (MR) # 1 and 2, 2 of 2 records reviewed for patients in seclusion. This had the potential to affect all patients treated at the facility.

Findings include:

Bullock County Hospital Policies and Procedures effective 4/2014
Manual: Gateway
Title: Patient Seclusion

" Policy: Patient seclusion in the Gateway Behavioral Unit is a serious matter and will be used only when other less restrictive methods have failed.

Purpose: The purpose of patient seclusion is to provide a safe, quiet, therapeutic environment for patients.
I. Appropriate Initiation of Patient Seclusion
E. Seclusion shall be used for the shortest period of time necessary to enable the patient to effectively cope with his or her environment.
F. The rights of the patient shall be preserved at all times during the use of seclusion in a compassionate manner while maintaining the patient's dignity as much as possible while providing for the safety of others...
III. Implementation of Patient Seclusion
E. Patients placed into seclusion shall have a protected, private, observable environment that safeguards their personal dignity and well-being...
VI. New Order Implementation and Rationale
F. Unit Staff who initiated the seclusion shall document in the patient's medical record the use of alternative strategies including preventive, de-escalate, and verbal intervention techniques which were attempted before the use of seclusion...
H. As soon as feasible after seclusion has been implemented the RN (Registered Nurse) shall discuss at least the following with the patient:
1) The specific behaviors that necessitated seclusion
2) How the individual's behavior continues to meet the criteria
3) The behaviors that shall be demonstrated in order to be released from seclusion
4) The patient's suggestion regarding staff actions that can assist the individual in gaining release from seclusion...
VII. Seclusion Precautions and Activities by staff
D. Adequate respiration and circulation shall be ensured at all times for the patient in seclusion.
E. While in seclusion, the patient shall be allowed the following:
1) Bathroom privileges at least once every two (2) hours, or more frequently when indicated
2) An opportunity to drink water or other appropriate liquids every two at hours, or more frequently when indicated...
X. Removal from Seclusion and Documentation
A. There shall be RN documentation at least every two (2) hours in the electronic health record to clinically justify the continued use of seclusion...
XIII. Seclusion Staff Routines
E. For each use of emergency seclusion, the Utilization Review Nurse of the unit shall be responsible for maintaining a central file containing, at a minimum, the following information:
1) Patient name and medical record number
2) Age, gender, and race
3) Date, time/shift, and day of week
4) Date and time seclusion started
5) Date and time seclusion discontinued
6) Total time patient was in seclusion
7) Injuries occurring during seclusion
8) Name and credentials of staff involved in the initiation of the seclusion
F. An Occurrence Report shall be completed for each episode of seclusion and shall become a part of the CQI (continuous quality improvement) Program."

1. MR # 1 was admitted to the facility on 3/20/17 with diagnosis including Post Traumatic Stress Disease with Acute Exaceberation and Opioid and THC (Tetrahydrocannabinol) dependence Disorder.

Record review revealed a physician order for seclusion dated 3/20/17, seclusion begin at 10:40 PM with continued seclusion at 2:38 AM.

Review of the facility seclusion documentation revealed the patient was in seclusion for over 7 hours, from 10:40 PM on 3/20/17 to 5:45 AM on 3/21/17. There was no documentation a patient assessment was completed from seclusion initiation through seclusion termination.

There was no documentation the staff offered fluids and toileting every 2 hours at 12:40 AM and 4:40 AM.

Review of the Patient Rounding Flowsheet completed by the nurse failed to reveal the accurate location of the patient on 3/20/17 at 10:00 PM to 3/21/17 at 4:00 AM. The patient was in the seclusion room. The nurse documented the patient was in the "bedroom", not in the seclusion room.

Record review revealed a Multidisciplinary Treatment Plan that was not updated for the 3/20/17 and 3/21/17 seclusion time.

Review of the facility documentation for occurrences titled Submission Management, Patient Safety Organization from February 2017 to August 2017 failed to include the seclusion occurrences for MR # 1 that occurred on 3/20/17 and 3/21/17.

In an interview on 9/14/17 at 10:59 AM, Employee Identifier (EI) # 1, Chief Nursing Officer, confirmed the above findings.

2. MR # 2 was admitted to the facility on 4/5/17 with diagnosis including Psychosis, Unspecified and discharged on 4/11/17.

Record review revealed a physician order for seclusion dated 4/6/17 at 5:00 PM.

Further review revealed a Registered Nurse (RN) documented pt (patient) ran and threw himself against the windows and doors in the Dayroom attempting to flee the unit. There was no signature of the RN who completed the documenting. There was no documentation staff completed the explanation/education for seclusion initiation and behavior necessary for discontinuation of seclusion.

Further review revealed the patient was placed in seclusion from 5:15 PM to 8:35 PM. There was no patient assessment, vital signs, toileting or food/fluid offering documented every 2 ours as required at 7:15 PM. There was no documentation a patient and staff debriefing was completed after seclusion had ended at 8:35 PM.

Review of the patient treatment plan failed to include an update to the treatment plan for the 4/6/17 seclusion.

Review of the facility documentation for occurrences titled Submission Management, Patient Safety Organization from February 2017 to August 2017 failed to include the seclusion occurrence for MR # 2 on 4/6/17.

In an interview on 9/14/17 at 11:17 AM, EI # 1 confirmed the above findings.

Based on review of the Quality Improvement Plan and interview, it was determined:

a) The facility failed to utilize and develop a Quality Improvement Plan to include problem solving and to improve patient care and safety,

b) The facility failed to assess the effectiveness of action taken,

c) The governing body failed to monitor the effectiveness of the Quality Assurance Program.

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

Findings include:

Refer to A 0273, A 0286, A 0297, 0308, and 0309

Based on review of the Quality Improvement Plan, Seclusion/Restraint Logs, Pharmacy failed to report errors and interview, it was determined the facility failed to implement a Quality Improvement Plan to include quality indicators and collection of data, recommendations for improvement and improved patient outcomes. This had the potential to negatively affect all patients served by this facility.

Findings include:

Performance Improvement and Patient Safety Plan, Bullock County Hospital

Introduction

... The intent of the Performance Improvement and Patient Safety Plan is to identify the facility's systematic approach to improving and sustaining its performance through prioritization. design, implementation, monitoring and analysis of performance improvement activities. Moreover, The Performance Improvement and Safety Plan is an ongoing program that demonstrates measurable improvement in indicators for which there is evidence that they will improve patient outcomes, and identify and reduce medical errors.
...

1. Providing a safe environment for all patients, visitors, and staff.
2. Performing patient care services in a timely and efficient manner.
3. Participation of all staff in Performance Improvement activities.

When data analysis deities a problem or trend, proactive risk reduction activities or a corrective action plan will be developed and implemented by the Department Head.

These actions may include:
...
2. Knowledge Enhancement - in-service education, continuing education and circulating informational material.

3. Intensive Reviews/ Focus Studies - When a medical/ health care system error- related occurrence is identified, proactive risk assessment activities are implemented including intensive review and/ or a focused study. A data collection tool is developed to address processes, functions, and services that can be designed or redesigned to prevent trends that may have contributed to the problems. Once all charts are reviewed, a summary report is complied to report conclusions.

4. Root Cause Analysis - When a medical/ health care error is classified by Administration as a Near Miss or Sentinel Event, the recommended Root Cause Analysis is format by The Joint Commission (TJC) is used to detect the underlying cause of the variation. ...

5. Failure Mode Effects Analysis - ...

6. Behavior Changes - Informal or formal counseling, consulting, changes in assignments and disciplinary action.

7. Policy Revisions - ...

8. Multidisciplinary Process team - ...

9. Operational Changes - ...

An interview was conducted with Employee Identifier (EI) # 3, Quality Assessment & Performance Improvement (QA), Infection Control Practitioner (ICP) and Employee Health (EH) Registered Nurse (RN) on 9/13/17 at 10: 45 AM.

During the interview the surveyor requested EI # 3 provide a sampling of the departmental Performance Indicators (PI) submitted by each department.

Health Information Management (HIM) -

1. PI was History and Physical (H&P) Note on chart in 24 hours the goal was zero (O) -
Results. 2017 January was 67.7, February was 68, March was 60, April was 65, May was 50, June was 52 , July was 55 and August was 49. EI # 3 stated that EI # 2, Administrator spoke with the physician regarding the late H&P's (History & Physicals). The surveyor requested to review the documentation, EI # 3 stated the team failed to documentation the discussion.

2. PI was Verbal Orders (VO) authentication greater than two days the goal was O-
Results: 2017 February was 18, March was 51. April was 32, May was 20, June was 26, July was 24 and August was 23. When asked what was the action plan, EI # 3 did not have any answer.

2. Gateway Unit -
1. PI was Restraint Usage with the goal less than or equal to 3.
Result - 2017 April - 0 and May was 0.
Review of the Seclusion/Restraint Logs for April 2017 and May 2017 revealed there were 2 patients for April and 1 patient in May 2017 that were placed on seclusion.

Review of the QA monthly meeting agenda dated 1/10/17, 4/25/17, 5/9/17 and 8/8/17 revealed no documentation discussion, recommendation or resolution regarding HIM concern about H&P not on the chart in 24 hours and authenticating of VO in less than 2 days.

In an interview conducted with EI # 3 on 9/13/17 at 10:50 AM, EI # 3 confirmed the above mentioned findings.



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During a tour of the facility's pharmacy on 9/12/17 at 10:30 AM survey staff observed 4 vials of (Demerol) Meperidine HCL (hydrochloride) Inj. (injection) 50 mg (milligram)/ml (milliter) stored in a ziplock bag located inside of a locked cabinet with a note attached stating, EI # 6, RN (Inactive) found medications on 1/19/17, and EI # 7, RN (Inactive) tampered with 3 vials of Demerol. The surveyor asked the EI # 5, pharmacist, "Why are these medications isolated from the other medications?" EI # 5 stated, we had a nurse diverting medications but she/he is no longer working here; The Alabama Board of Nursing (ABN) was notified of the incident and actions were taken against the nurse's license.

The surveyor asked EI # 5, "Who reported the incident?" EI # 5 stated EI # 6 went into the Omnicell medication cabinet to get a vial of Demerol to administer and noticed the lids on 3 vials of Demerol had been tampered with. The nurse reported his/her findings to the nurse manager and EI # 5 was notified as well. EI # 5 stated, she/he sequestered 4 vials of Demerol from the Omnicell medication cabinet to keep as evidence. EI # 5 stated 3 of the vials were clearly tampered with but he/she decided it would be best to remove the fourth vial because he/she could not determine if the fourth vial had been tampered with.

The surveyor asked EI # 5, "What changes did the facility make to prevent this type of diversion from happening again?" EI # 5 stated, "The nurse was fired and the ABN was notified."

The surveyor asked EI # 5, "Did you discuss and document this incident in the facility Quality Assurance process?" EI # 5 stated, "No."

Review of the QA monthly meeting agenda dated 2/9/17, and 4/25/17 revealed no documented discussion, recommendation or resolution regarding the diversion of medication or near miss medication error. The facility's pharmacy services failed to take measures to identify, review, and prevent ways to minimize diversions, near miss, and medication errors.

An interview was conducted on 9/12/17 at 10:30 AM with EI # 5 who confirmed the above findings.

Based on review of hospital policies and procedures and staff interviews it was determined the facility failed to provide a Quality Assurance and Performance Improvement (QAPI) program to include:

1. Indicators to identify and reduce medical errors.

2. A process for staff to report blood transfusion reactions and reviews of reported blood transfusion reactions to identify medical errors.

This had the potential to affect every patient served by the hospital.

Findings include:

Performance Improvement and Quality Assurance - Bullock County Hospital
Effective Date: 10/2012

Policy

Bullock County Hospital's Performance Improvement and quality Assurance Plans are designed to provide systematic and organized program for the promotion of safe and effective patient care. ... The organization has the responsibility of designing, measuring, assessing and improving its performance and patient safety.

Procedure

The plans will allow for the implementation of continuous quality improvement through the following:

The recognition that all individuals are responsible for quality of care/ services, patient safety, and performance improvement.


During a review of the Performance Indicators Worksheet, with Employee Identifier (EI) # 3, Quality Assessment/ Performance Improvement (QA/PI) Registered Nurse (RN), it was determined the pharmacist monitors and tracks expired medications.

Review of the Pharmacy Department QA/ PI indicator revealed the pharmacist tracks medication discrepancies, but they were not reported or included in the hospital-wide QAPI program.

Review of the Laboratory Department QA/ PI indicators revealed the director reports blood transfusion and reactions, positive cultures, cross match to transfusion ratio, wasted units and single unit crossmatch.

Review of the Performance Indicators provided by EI # 3 on 9/13/17 at 10:50 AM revealed the following areas were not being reported to the hospital-wide QA: positive cultures, single unit cross match and cross match to transfusion ratio.

An interview was conducted on 9/13/17 at 10:50 AM with EI # 3, who confirmed the aforementioned findings.

Based on review of the hospital policy, Quality Assessment and Performance Improvement and interview with the Quality Assurance (QA) Registered Nurse (RN) , 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:

Performance Improvement and Quality Assurance - Bullock County Hospital
Effective Date: 10/2012

Policy

Bullock County Hospital's Performance Improvement and quality Assurance Plans are designed to provide systematic and organized program for the promotion of safe and effective patient care. ... The organization has the responsibility of designing, measuring, assessing and improving its performance and patient safety.

Procedure

The plans will allow for the implementation of continuous quality improvement through the following:
...

Recommendations for resolutions of problems and opportunities to improve patient care, safety and services.
Assessment of the effectiveness of actions taken by initiation of ongoing monitoring.
Emphasizing education rather than punitive measures.

Goals

The goals of the program are as follows:

To improve patient care, safety, quality and services by measuring, assessing, and improving those clinical and support processes that most affect patient outcomes.
...
To organize data into useful information.
...
To provide and promote a mechanism for the integration and documentation of all performance improvement.
To enhance communication between Medical Staff, Hospital Department/ Services, and the Governing Body regarding the conclusions and recommendations resulting from review activities and the actions taken to address the findings and recommendations.

Monitoring and Evaluation Process

The hospital will conduct a Root Cause Analysis (RCA) in response to serious events (see attachment: "The National Quality Forum List of Serious Reportable Events"). The RCA involves an internal investigation and assessment of the event to prevent the event from recurring in the future. The RCA will focus primarily on system and processes rather than individual performance

An interview was conducted on 9/13/17 at 10:50 AM with Employee Identifier # 3, Quality Assessment, Performance Improvement (QAPI) Registered Nurse who was unable to provide the surveyor reasons for choosing each department performance indicators and measures for resolutions and effectiveness of the solutions.

Based on the review of the Quality Assurance Plan and interview, it was determined the governing body of the facility failed to ensure there was Quality Assurance Plan implemented. This had the potential to negatively affect all patients served by this facility.

Findings include:

Performance Improvement and Quality Assurance - Bullock County Hospital
Effective Date: 10/2012

Policy

Bullock County Hospital's Performance Improvement and quality Assurance Plans are designed to provide systematic and organized program for the promotion of safe and effective patient care. ... The organization has the responsibility of designing, measuring, assessing and improving its performance and patient safety.

Organization and Responsibility

A. Governing Board:

The Board of Directors shall review and evaluate patient care activities to assess, preserve, and improve the overall quality, safety and efficiency of patient care and services in the hospital. While maintaining overall responsibility, the Board delegates operational a authority to the Medical Staff and administration. In exercising its supervising responsibility, the Board will:

Receive and review results of performance improvement activities, and recommend prioritization and reprioritization of activities as needed.
Assess, at least annually, the program effectiveness and efficiency, and request modifications in organizational structure systems, where necessary, to improve program activities.
Provide for resources and support systems for quality improvement and risk management functions related to patient care safety.

An interview was conducted with Employee Identifier # 3, Quality Assurance (QA)/ Performance Improvement (PI)/ Infection Control Practitioner and Employee Health Nurse on 9/13/17 at 11:45 AM, who confirmed audit reports submitted by each department director was not reported to the Medical Staff or the Governing Body. Further review of the QA/ PI program revealed no annual assessment or program effectiveness was performed.

Based on review of hospital policy and procedures and staff interviews it was determined the governing body failed to ensure:

1. The Performance Improvement and Quality Assurance (PI/ QA)

(a) Included indicators to identify and reduce medical errors.
(b) Included a process for staff to report blood transfusion reactions and reviews of reported blood transfusion reactions to identify medical errors.

2. The number of distinct improvement projects to be conducted annually was determined.

3. Approve the improvement projects included in the PI/ QA program.

This had the potential to affect every patient served by the hospital.

Findings include:

Performance Improvement and Quality Assurance - Bullock County Hospital
Effective Date: 10/2012

Policy
... Through an interdisciplinary and integrated process, patient care and processes that affect patient care outcomes shall be continuously monitored and evaluated to promote optimal achievements, with appropriate accountability assumed by the Governing Body, Medical Staff and Senior Administration and staff. The organization has the responsibility of designing, measuring, assessing, and improving its performance and patient safety.

Scope of Activities
Activities will be designed to assess key functions of patient care and to identify, study, and correct problems and improvement opportunities found in the process of patient care delivery.

A. Governing Body
The Governing Body shall review and evaluate patient care activities to assess, preserve, and improve the overall quality, safety and efficiency of patient care services in the hospital.

B. Medical Staff
The Medical Staff is accountable to the Board of Directors for the oversight of monitoring and evaluative functions to determine that an acceptable level of care is rendered to all patients. ...
The Medical Staff will receive a summary report of all quality improvement activities at least quarterly.

C. Senior Management

The leadership of Bullock County Hospital assumes responsibility for the quality and safety of care performance and shall actively support the program ...

D. Hospital Departments

The Department Directors are accountable to Administration, the Medical Staff, the Board of Directors and members of committee for the quality and safety of care/ services and performance of their staff and departments. ...

E. Performance Improvement Committee

The committee has an oversight responsibility for all Performance Improvement activities conducted throughout the hospital. ...


During review of the Performance Indicator , it was determined that the pharmacist monitored and tracked medication errors but failed to report them as a part of the hospital-wide QA/PI program and the laboratory department reviewed positive cultures, cross match to transfusion ratio, and single unit crossmatch were reviewed but were not reported to or included in the hospital-wide QA/PI program.

There was no documentation the above written findings were presented to the Governing Body.

An interview was conducted on 9/13/17 at 11:45 AM with Employee Identifier # 3, Quality Assurance/Performance Improvement (QA/ PI) Registered Nurse, who confirmed the aforementioned findings.

Based on review of medical records (MR), policy, observation and interview it was determined the nurse failed to:

1) provide wound care as ordered and measure the wounds during wound care per facility policy. This affected observed patients with wound care and assessment including MR # 9, MR's # 13 and # 8.

2) adminster medications as ordered by the physician. This did affect MR # 1 and # 15, 2 of 5 psychiatric medical records reviewed.

3) document the anatomical location for intramuscular (IM) medication administration and theraputic effectivenness of prn (as needed) medications. This affected MR # 2 and # 3, 2 of 5 psychiatric medical records reviewed.

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

Findings include:

Policy: Wound Care
Revised Date: 8/2017

Purpose

To provide consistent wound care protocols to assess, maintain and promote skin integrity.

Procedure

Physician's orders will be followed for wound care procedures.

Wound Documentation

If more than one wound, number each wound document in flow sheet.
Measure each wound (in centimeters) for length/ width/ depth.
Assess for drainage, odor, color , tunneling or undermining.
Care provided to include dressing type, cleansing and any other ordered interventions.

Patient/ Family Education

Information will be given regarding wound care and follow-up
Document teaching in nurses's note.

1. MR # 9 was admitted to the hospital on 8/25/17 with the diagnoses including Acute Urinary Tract Infection and Volume Depletion.

Review of the Physician's Order revealed wound care orders as follows: Clean coccyx area and apply Silvadene cream to area daily and as needed (PRN).

Review of the Nurse's Notes (NN) on 8/25/17 at 9:25 PM revealed the assessment documentation the patient had a Stage II ulcer to coccyx and multiple open areas to perineum and testicles. There was no documentation the wound was assessed, measured and the type of dressing applied.

Review of the NN on 8/26/17 at 8:20 PM revealed wound care was provided. There was no documentation the wound was assessed, measured and type of dressing applied.

Review of the NN on 8/27/17 at 8:30 PM revealed wound care was provided. There was no documentation the wound was assessed, measured and type dressing applied. Further review of the NN revealed documentation the staff used normal saline (NS) to cleaned the wound. There was no Physican's order to cleaned the wound with NS,

Review of the NN on 8/28/17 at 8:30 PM revealed wound care was provided. There was no documentation the wound was assessed, measured and type of dressing applied.

There was no documentation wound management and care was provided on 8/29/17.

Review of the NN on 8/30/17 at 9:45 PM revealed no wound care was provided. Further review of the note revealed the documentation of presence of foul odor was noted. There was no documentation the physician was notified.

There was no documentation wound care management was provided on 8/31/17 and 9/1/17.

An interview was conducted on 9/14/17 at 11:40 AM with Employee Identifier (EI) # 1, Chief Nursing Officer (CNO) who confirmed the staff failed to follow facility wound care policy and physican wound care orders.

2. MR # 13 was admitted to the hospital on 6/12/17 with the admitting diagnosis of Weakness.

Review of the Physician's Orders revealed the following wound care orders: Cleanse right great toe with Normal Saline (NS), pat dry with gauze, apply soaked saline gauze to wound bed and wrap with 4x4 gauze. Secure with tape. Perform wound care daily. Apply Calazime cream to side of right "pinky" toe daily.

Review of the NN (notes) dated 6/12/17, 6/14/17, 6/15/17, 6/16/17 and 6/17/17 revealed no documentation wound care was provided and no wound measurements were documented.

An interview was conducted on 9/14/17 at 11:55 AM with EI # 1, who confirmed the above mentioned findings.




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3. MR # 8 was admitted to the facility on 5/8/17 with diagnoses including chest pain.

Review of the Physician (MD) Orders dated 5/8/17 at 3:00 PM revealed: "Clean left leg lower open area with normal saline, using gauze, pat dry, apply silvadene cream use sterile gauze and tape daily..."

Review of Nurse's Notes dated 5/10/17 revealed there was no documentation that wound care was provided daily per MD order. There was no documentation the wound was assessed, measured, and dressing was applied on 5/10/17 per physician order, and policy and procedure.

An interview was conducted on 9/14/17 at 11:45 AM with EI # 1, who confirmed the staff failed to follow physican's orders on wound care.



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4. MR # 1 was admitted to the facility on 3/20/17 with diagnosis including Post Traumatic Stress Disease with Acute Exaceberation and Opioid and THC (Tetrahydrocannabinol) dependence Disorder.

Review of the Medication Administration Record documentation revealed on 3/21/17 Seroquel 100 milligram (mg) by mouth at noon was ordered by the physician. There was no documentation the Seroquel 100 mg at noon was administered on 3/25/17. There was no documentation the patient refused and no documentation the physician was notified.

In an interview on 9/14/17 at 10:59 AM, EI # 1 confirmed the above findings.

5. MR # 2 was admitted to the facility on 4/5/17 with diagnosis including Psychosis, Unspecified. MR # 2 was discharged on 4/11/17.

Review of the Medication Administration Record documentation revealed on 4/6/17 at 5:00 PM Ativan 2 mg po (by mouth) or IM (intramuscularly) every 6 hours prn (as needed), Haldol 5 IM po or IM every 6 hours prn Psychosis, Benadryl 50 mg IM every 6 hours prn EPS (extrapyramidal side effects) was administered by staff.

There was no documentation of the anatomical location the IM medications were administered and no documentation of the therapeutic effectiveness of the 3 medications.

In an interview on 9/14/17 at 11:17 AM, EI # 1 confirmed the above findings. EI # 1 reported she/he assumed all medications were given IM since Benadryl was only ordered IM.

6. MR # 3 was admitted to the facility on 8/30/17 with diagnosis including Mood Disorder, Unspecified with Suicidal and Homicidal Ideations. MR # 3 was discharged on 9/13/17.

Review of the Medication Administration Record documentation revealed on 9/5/17 at 8:30 PM Benadryl 50 mg IM every 6 hours prn agitation and Haldol 5 po or IM every 6 hours prn Psychosis was administered by staff.

There was no documentation of the anatomical location the IM medications were administered and no documentation of the therapeutic effectiveness of the 2 medications.

Review of the Medication Administration Record documentation revealed on 8/31/17 at 8:00 PM Vistaril 25 mg po every 6 hours prn anxiety given. There was no documentation of the therapeutic effectiveness of the Vistaril.

In an interview on 9/14/17 at 1:47 PM, EI # 1, confirmed the above findings.

7. MR # 15 was admitted to the facility on 7/5/17 with diagnosis including Panic Disorder with Agoraphobia. MR # 15 was discharged on 7/12/17 at 2:20 PM.

Review of the Medication Administration Record documentation revealed on 7/9/17 at 9:00 PM Trazadone 100 mg at bedtime was ordered but not administered. Phenobarbital 30 mg 2 tabs 4 times a days was ordered at 9:00 PM on 7/9/17 but not administered and Cataprel 333 mg 2 tabs three times a day ordered at 9:00 PM but not administered.

There was no documentation the patient refused the 3 medications or that the physician was notified the medications were not administered as ordered.

In an interview on 9/14/17 at 11:10 PM, EI # 1, confirmed the above findings.

Based on review of the facility policy and procedure, medical record and interview, it was determined the facility failed to provide patients with group therapy as documented in the patient treatment plan and there was no physician participation/ approval in development of the Treatment Plan documented.

This affected Medical Record (MR) # 3, # 2 and # 4, 3 of 5 psychiatric patient records reviewed and had the potential to affect all patients treated at the Gateway Behavioral Health Unit (BHU).

Findings include:

Bullock County Hospital
Policies and Procedures effective date 4/2014
Manual: Gateway
Title: Treatment Team Meetings

" Policy: Each patient's individualized treatment plan shall be continuously reviewed, evaluated, and updated during the course of the patient's hospitalization.
Procedure:

A. The Multidisciplinary Treatment Team, led by the patient's attending physician will formally update the treatment plan daily at the patient staffing meeting...
D. Each member of the treatment team responsible for implementing the recommendations resulting from a review of the plan of care shall revise the treatment plan following the staffing as indicated...
G. Documentation in the progress notes will be completed by a treatment team member to include the nature and the extent of the patient's involvement as well as the family and/or advocate's participation during treatment team meetings."

1. MR # 3 was admitted to the facility on 8/30/17 with diagnosis including Mood Disorder, Unspecified with Suicidal and Homicidal Ideations. MR # 3 was discharged on 9/13/17.

Record review revealed a Multidisciplinary Treatment Plan which included short-term goals, dated 9/5/17, patient will attend and participate in 3 counseling sessions per week.

Record review revealed 1 counseling session dated 9/7/17, no begin and end time of the session was documented.

There was no documentation the counselor attempted to perform 3 counseling sessions the week of 9/5/17 and no documentation the patient refused to attend the counseling sessions.

In an interview on 9/14/17 at 10:42 AM, Employee Identifier (EI) # 1, Chief Nursing Officer confirmed the above finding.

2. MR # 2 was admitted to the facility on 4/5/17 with diagnosis including Psychosis, Unspecified and discharged on 4/11/17.

Record review revealed a physician order for seclusion dated 4/6/17 at 5:00 PM in which the Registered Nurse documented pt (patient) ran and threw himself against the windows and doors in the Dayroom attempting to flee the unit.

Review of the patient treatment plan failed to include an update to the treatment plan for the 4/6/17 seclusion.

Record review revealed a Multidisciplinary Treatment Plan for admission to the unit dated 4/5/17 for nursing, 4/6/17 for counseling, 4/7/17 for case management and 4/6/17 for activities. There was no documentation of the psychiatrist signature and date for participation and approval of the Treatment Plan.

In an interview on 9/14/17 at 11:17 AM, EI # 1 confirmed the above findings.

3. MR # 4 was admitted to the facility on 8/25/17 with diagnosis including Schizoaffective Disorder, bipolar Type, Manic and Delusional. The patient was discharged on 9/13/17 at 10:40 AM.

Record review revealed a Multidisciplinary Treatment Plan which included short-term goals, dated 8/25/17, patient will attend and participate in 3 counseling sessions per week.

Record review revealed 2 counseling sessions which were on 8/28/17 and 9/4/17 with no begin and end time of the session documented.

There was no documentation the counselor attempted to perform 3 counseling sessions the week of 8/27/17 and no documentation the patient refused to attend the counseling sessions.

In an interview on 9/14/17 at 10:42 AM, EI # 1, confirmed the above finding.

Based on review of medical record (MR) and interview, staff documented MR # 4 and # 15 activity on the Observation Log prior to the actual time observations were completed. This affected 2 of 5 psychiatric medical records reviewed and had the potential to affect all patients treated at Gateway Behavioral Health Unit.

Findings include:

1. MR # 4 was admitted to the facility on 8/25/17 with diagnosis including Schizoaffective Disorder, Bipolar Type, Manic and Delusional. The patient was discharged on 9/13/17 at 10:40 AM.

Review of the Observation log documentation revealed at 10:45 AM to 11:30 AM on 9/13/17 staff had documented an activity code and staff initials for patient observations completed then marked through the documentation such that it was barely legible.

In an interview on 9/14/17 at 10:42 AM, Employee Identifier (EI) # 1, Chief Nursing Officer, confirmed staff documented prior to the occurrence of actual events. The patient had been discharged.

2. MR # 15 was admitted to the facility on 7/5/17 with diagnosis including Panic Disorder with Agoraphobia. MR # 15 was discharged on 7/12/17 at 2:20 PM.

Review of the Observation log documentation revealed at 2:30 PM to 5:00 PM on 7/12/17 staff documented an activity code and staff initials for patient observations completed after the patient was discharged. Staff then marked through the documentation such that it was barely legible.

In an interview on 9/14/17 at 11:10 AM, EI # 1, confirmed the above findings.

Based on review of medical record (MR), hospital policy and interviews, it was determined the hospital staff failed to ensure the patient's history and physical (H&P) was completed within 24 hours after admission per policy. This did affect MR # 7 and # 12, 2 of 15 inpatient records reviewed. This had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: Dictation of H&P and Discharge(D/C) Summary
Number: HIM 001
Revised: January 2014

"Policy
To assure that all H&Ps and D/C summaries are on the chart according to CMS (Centers for Medicare and Medicaid Services) guideline.

Procedure
Physician are to dictate the H&P of any patient under their services according to CMS guideline which is 24 hrs (hours) for H&P and 30 days for D/C summary."

1. MR # 7 was admitted to the hospital on 6/2/17 with the diagnosis of Low Blood Pressure.

Review of the H&P revealed it was not dictated until 6/12/17, transcribed until 6/13/17 and signed by the physician until 7/26/17 .

During an interview on 9/14/17 at 11:50 AM with Employee Identifier (EI) # 1, Chief Nursing Officer, the above findings were confirmed.

2. MR # 12 was admitted to the hospital on 5/6/17 with the diagnosis of a Motor Vehicle Accident.

Review of the H&P revealed it was not dictated until 5/16/17, transcribed until 5/17/17 and signed by the physician on 7/19/17 .

During an interview on 9/14/17 at 11:35 AM with EI # 1, the above findings were confirmed.

Based on review of medical record (MR) reviews, hospital policy and interviews, it was determined the hospital staff failed have medical records completed within 30 days following discharge. This did affect MR # 7, # 12 and # 2, 3 of 15 inpatient medical records reviewed. This had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: Dictation of History and Physical(H&P) and Discharge(D/C) Summary
Number: HIM 001
Revised: January 2014

"Policy
To assure that all H&Ps and D/C summaries are on the chart according to CMS guideline.

Procedure
Physician are to dictate the H&P of any patient under their services according to CMS guideline which is 24hrs(hours) for H&P and 30 days for D/C summary."

1. MR # 7 was discharged from the hospital on 6/5/17 with the diagnoses including Acute Colitis, Hypotension, resolved, and Volume Depletion, Resolved.

Review of the D/C summary revealed it was dictated on 6/12/17, transcribed on 6/13/17. The physician signed the DC summary on 7/26/17, which was 50 days after discharge.

In an interview on 9/14/17 at 11:50 AM with Employee Identifier (EI) # 1, Chief Nursing Officer, confirmed the facility policy for completion of the D/C summary was not followed.

2. MR # 12 was discharged from the hospital on 5/8/17 after being treated for injuries sustained in a Motor Vehicle Accident.

Review of the D/C summary revealed that the physician failed to include a list of diagnoses at the time of discharge.

Review of the D/C summary revealed it was dictated on 5/16/17 , transcribed on 5/17/17 but not signed by the physician until 7/19/17.

During an interview on 9/14/17 at 11:35 AM with EI # 1, the above findings were confirmed.




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3. MR # 2 was admitted to the facility on 4/5/17 with diagnosis including Psychosis, Unspecified. MR # 2 was discharged on 4/11/17.

Record review revealed no physician signature and date on the Discharge Summary as of 9/14/17.

In an interview on 9/14/17 at 11:17 AM, EI # 1, confirmed the above finding.

This condition level deficiency is cited based on review of the facility policies and procedures, observation, and interview, it was determined the facility failed to ensure:

1. Staff take measures to identify, prevent, and minimize diversion of medications and medication errors. Refer to A 491 and A 508.

2. Staff store, dispense, and manage medications according to the facility policy. Refer to 494.

3. The patients received the amount of (Demerol) Meperidine HCL (Hydrochloride) Inj. (Injection) 50 mg (Milligram)/ ml (Milliliter) ordered by the physician. Refer to A 500.

4. Staff stored, dispensed, and managed medications according to the facility policy. Refer to A 502 and A 503.

5. All medications and non-medication supplies available for patient use were not expired. Refer to A 505.

Refer to A 491, A 494, A 500, A 503, A 505, and A 508 for additional findings.

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

Based on review of facility policies and procedure, observations and interviews, it was determined the staff failed to take measures to identify, prevent, and minimize diversion of medications and medication errors. This had the potential to negatively affect all patient's served by this facility.

Findings include:

Title: Controlled substances
Revised 6/16/2014

"Policy:

It is the policy of Bullock County Hospital to ensure that strict control will be maintained on all controlled substances. This requires compliance with the following procedures in a joint effort by the nursing staff and pharmacy staff..."

1. During a tour of the facility's pharmacy on 9/12/17 at 10:30 AM survey staff observed 4 vials of (Demerol) Meperidine HCL (hydrochloride) Inj. (injection) 50 mg (milligram)/ml (milliters) stored in a ziplock bag located inside of a locked cabinet with a note attached stating, EI (Employee Identifier) # 6, RN (Inactive) found medications on 1/19/17, and EI # 7, RN (Inactive) tampered with 3 vials of Demerol. The surveyor asked EI # 5, pharmacist, "Why are these medications isolated from the other medications?" EI # 5 stated, we had a nurse diverting medications but she/he is no longer working here; The Alabama Board of Nursing (ABN) was notified of the incident and actions were taken against the nurse license.

The surveyor asked EI # 5, "Who reported the incident?" EI # 5 stated EI # 6 went into the Omnicell medication cabinet to get a vial of Demerol to administer and noticed the lids on 3 vials of Demerol had been tampered with. The nurse reported his/her findings to the nurse manager and EI # 5 was notified as well. EI # 5 stated, she/he sequestered 4 vials of Demerol from the Omnicell medication cabinet to keep as evidence. EI # 5 stated 3 of the vials were clearly tampered with but he/she decided it would be best to remove the fourth vial because he/she could not determine if the fourth vial had been tampered with.

The surveyor asked EI # 5, "What changes did the facility make to prevent this type of diversion from happening again?" EI # 5 stated, "The nurse was fired and the ABN was notified."

The surveyor asked EI # 5, "Did you discuss and document this incident in the facility Quality Assurance process (QA)?" EI # 5 stated, "No."

Review of the QA monthly meeting agenda dated 2/9/17, and 4/25/17 revealed no documented discussion, recommendation or resolution regarding the diversion of medication or near miss medication error. The facility's pharmacy services failed to report and take measures to identify, review, and prevent ways to minimize diversions, near miss, and medication errors in the facility's QA program.

An interview was conducted on 9/12/17 at 10:30 AM with EI # 5 who confirmed the above findings

Based on review of facility policies and procedure, observations and interviews, it was determined the staff failed to store, dispense, and manage medications according to the facility policy. This had the potential to negatively affect all patients served by this facility.

Findings include:

Title: Controlled Drug Access
Revised Date: 11/2013

"Policy:

It is the policy of Bullock County Hospital that in order to regulate the movement of controlled medication, only those who have need and are duly authorized will have access to certain supplies of controlled substances.

Procedure:

1. The central Pharmacy controlled substance supply is only accessible to authorized Pharmacy personnel. These personnel includes: Director of Pharmacy and/or Staff Pharmacists, and Pharmacy Technicians..."

********

Title: Controlled substances
Revised 6/16/2014

"Policy:

It is the policy of Bullock County Hospital to ensure that strict control will be maintained on all controlled substances. This requires compliance with the following procedures in a joint effort by the nursing staff and pharmacy staff.

Procedure:

1. A controlled substance record or pharmacy record book is maintained, which lists on separate sheets for each type and strength of controlled drug, the following information: Date and Time the medication was taken from Omnicell, the number taken, the number left in pharmacy stock, and the signature of the employee removing the narcotic, from the pharmacy narcotic cabinet...

3. ...Refrigerated narcotics will be stored in a locked box, inside of the locked refrigerator...

5. ...If the narcotic count is off the DON (Director of Nursing), or department manager is notified. The DON and the department manager will try to resolve the narcotic count discrepancy. If the discrepancy can't be resolved between the nursing staff, then the department manager, DON, will be responsible for informing the pharmacist. The pharmacist will then put forth all efforts to resolve the discrepancy."

1. During a tour of the facility's pharmacy on 9/12/17 at 10:30 AM survey staff observed expired medications inside a basket located in a locked cabinet which was marked as expired medications. The following drugs were inside the basket:

Diazepam Inj. (Injection) 10 mg (milligram) / 2 ml (milliters) carpuject X (times) 4 - expired (exp.) date 1/1/17.

Alprazolam 0.25 mg tab (tablet) X 91 - exp. date 2/2017.

Acetaminophen and Codeine Phosphate 300 mg / 30 mg tab X 92 - exp. date 7/2017.

Diphenoxylate Hydrochloride Atropine Sulfate Oral Solution 60 ml bottle - exp. date 6/2017.

Alprazolam 1 mg tab X 77 - exp. date 3/2017.

Morphine Sulfate Inj. 10 mg / ml 1 ml vial X 21 vials - exp. date 3/2017.

Hydrocodone Bitartrate and Acetaminophen 7.5 mg / 325 mg tab X 355 - exp. date 2/2017.

Tramadol HCL (hydrochloride) 50 mg tab X 4 - exp. date 4/2017.

The surveyor asked EI (Employee Identifier) # 5, Pharmacist, "Is there a log for tracking the expired narcotics that is being stored for disposal?" EI # 5 stated, "No." The pharmacy staff failed to document all expired controlled substances per policy.

The surveyor asked EI # 5, "What process do you have in place for narcotic disposal?"

EI # 5 stated, "We have a company (Co.) out of Birmingham that comes to the facility to pick up the expired medications and dispose them."

The surveyor asked, "How often does the Co. send out staff to dispose of the facility medications?" EI # 5 stated, "There is no specific time for the Co. to send out staff for medication disposal, whenever he/she is in the area he/she will stop by and pick up the medications for disposal. Someone usually come by the facility quarterly or every 6 months to pick up expired medications."

The surveyor asked EI # 5, "Do you have a number to call the company if you need them to pick up expired medications for disposal?" EI # 5 stated, "yes, but I haven't had to call the Co. because they come out."

The surveyor asked EI # 5, "Who has access to the pharmacy medications?" EI # 5 stated, "Myself, the Pharmacy Technician, and the Administrator has access to the pharmacy."

The surveyor asked EI # 5, "How would you know if anyone was diverting or stealing the expired narcotics if you are not keeping a log for tracking?" EI # 5 stated, "The contracted Co. (Med-Turn, Inc. [Incorporated]) will send out a reverse distributor staff member that will count all C2s (Controlled substance schedule 2 medications) and document the count on a DEA (Drug Enforcement Administration) 221 form. The reverse distributor staff will sign the form with EI # 5 before removing the medications from the pharmacy for disposal." The hospital's pharmacy service failed to ensure safe and appropriate storage, dispensing, tracking, control, and disposal of expired controlled medications.

An interview was conducted on 9/12/17 at 10:30 AM with EI # 5 who confirmed the above findings.

Based on observations and interview, it was determined the facility failed to ensure the patients received the amount of (Demerol) Meperidine HCL (Hydrochloride) Inj. (Injection) 50 mg (Milligram)/ ml (Milliliter) ordered by the physician. This had the potential to effect all patients served by this facility.

Findings include:

1. During a tour of the facility's pharmacy on 9/12/17 at 10:30 AM survey staff observed 4 vials of (Demerol) Meperidine HCL (hydrochloride) Inj. (injection) 50 mg (milligram)/ml (milliliter) stored in a ziplock bag located inside of a locked cabinet with a note attached stating, EI (Employee Identifier) # 6, RN (Inactive) found medications on 1/19/17, and EI # 7, RN (Inactive) tampered with 3 vials of Demerol. The surveyor asked the EI # 5, pharmacist, "Why are these medications isolated from the other medications?" EI # 5 stated, we had a nurse diverting medications but she/he is no longer working here; The Alabama Board of Nursing (ABN) was notified of the incident and actions were taken against the nurse license.

The surveyor asked EI # 5, "Who reported the incident?" EI # 5 stated EI # 6 went into the Omnicell medication cabinet to get a vial of Demerol to administer and noticed the lids on 3 vials of Demerol had been tampered with. The nurse reported his/her findings to the nurse manager and EI # 5 was notified as well. EI # 5 stated, she/he sequestered 4 vials of Demerol from the Omnicell medication cabinet to keep as evidence. EI # 5 stated 3 of the vials were clearly tampered with but he/she decided it would be best to remove the fourth vial because he/she could not determine if the fourth vial had been tampered with.

The surveyor asked EI # 5, "What changes did the facility make to prevent this type of diversion from happening again?" EI # 5 stated, "The nurse was fired and the ABN was notified."

An interview was conducted on 9/12/17 at 10:30 AM with EI # 5 who confirmed the above findings

Based on review of facility policies and procedure, observations, and interviews, it was determined the staff failed to store and manage medications according to the facility policy. This had the potential to negatively affect all patients served by this facility.

Findings include:

Title: Controlled substances
Revised 6/16/2014

"Policy:

It is the policy of Bullock County Hospital to ensure that strict control will be maintained on all controlled substances. This requires compliance with the following procedures in a joint effort by the nursing staff and pharmacy staff.

Procedure:

1. A controlled substance record or pharmacy record book is maintained, which lists on separate sheets for each type and strength of controlled drug, the following information: Date and Time the medication was taken from the Omnicell, the number taken, the number left in pharmacy stock, and the signature of the employee removing the narcotic, from the pharmacy narcotic cabinet...

3. ...Refrigerated narcotics will be stored in a locked box, inside of the locked refrigerator...


1. During a tour of the facility's pharmacy on 9/12/17 at 10:30 AM survey staff observed Ativan Inj. (injectable) 2 mg/ml (milligram/milliliter) 1 ml vials X (number) 115 was stored inside of a locked container inside the pharmacy refrigerator. The pharmacy refrigerator did not have a lock on it per facility policy.

An interview was conducted on 9/12/17 at 10:30 AM with Employee Identifier # 5, Pharmacist, who confirmed the above findings.

Based on observations and interviews, it was determined the facility failed to ensure all medications available for patient use were not expired. This had the potential to negatively affect all patient served by this hospital.

Findings include:

Subject: Emergency Drug Carts
Date Revised: November 2012

Policy

It is the policy of Bullock County Hospital to maintain carts/ kits equipped with a supply of drugs which are likely to be needed in emergency situation and are easily accessible.

Procedure:

It is the policy of Bullock County Hospital to maintain carts/ kits equipped with a supply of drugs which are likely to be needed in emergency situations and are easily accessible.

Procedure:

1. Bullock County Hospital has six different emergency drug supplies:
A. Emergency Room Adult Emergency Cart
B. Emergency Room Pediatric Emergency Cart
C. Med- Surg Adult Emergency Cart
D. Med- Surg Pediatrics Emergency Cart
E. Radiology Department
F. Times Treatment Room Emergency Kit

2. The drug stock in the emergency carts/ kits are to be checked monthly by Pharmacy personnel for completeness, accuracy and expire medications and fluids. Nursing personnel should also contact pharmacy if the carts are used to be checked and restocked.

7. After checking the drug items, the carts should be checked by either central supply or nursing personnel for all other non-drug items.


A tour of the Emergency Department (ED) was conducted on 9/12/17 at 11:15 AM. An observation of the crash cart was conducted and the following was observed:

1. Sterile Water 1 vial- expired on 8/2017

In an interview conducted on 9/12/17 at 11:20 AM with Employee Identifier (EI) # 4, Emergency Room Director who confirmed the above mentioned findings.



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During a tour of the Medical and Detoxification department on 9/12/17 at 3:43 PM the following expired supplies were observed in the crash cart:

Sterile Latex Surgical Gloves expired 08/2017.

Endotracheal Tube expired 4/2017

An interview was conducted on 9/12/17 at 3:45 PM with EI # 9, Registered Nurse who confirmed the above findings.

Based on review of facility policies and procedure, observations and interviews, it was determined the staff failed to take measures to identify, prevent, and minimize diversion of medications and medication errors. This had the potential to negatively affect all patient's served by this facility.

Findings include:

Title: Controlled substances
Revised 6/16/2014

"Policy:

It is the policy of Bullock County Hospital to ensure that strict control will be maintained on all controlled substances. This requires compliance with the following procedures in a joint effort by the nursing staff and pharmacy staff..."

1. During a tour of the facility's pharmacy on 9/12/17 at 10:30 AM survey staff observed 4 vials of (Demerol) Meperidine HCL (hydrochloride) Inj. (injection) 50 mg (milligram)/ml (milliliter) stored in a ziplock bag located inside of a locked cabinet with a note attached stating, EI (Employee Identifier) # 6, RN found medications on 1/19/17, and EI # 7, RN tampered with 3 vials of Demerol. The surveyor asked the EI # 5, pharmacist, "Why are these medications isolated from the other medications?" EI # 5 stated, we had a nurse diverting medications but she/he is no longer working here; The Alabama Board of Nursing (ABN) was notified of the incident and actions were taken against the nurse license.

The surveyor asked EI # 5, "Who reported the incident?" EI # 5 stated EI # 6 went into the Omnicell medication cabinet to get a vial of Demerol to administer and noticed the lids on 3 vials of Demerol had been tampered with. The nurse reported his/her findings to the nurse manager and EI # 5 was notified as well. EI # 5 stated, she/he sequestered 4 vials of Demerol from the Omnicell medication cabinet to keep as evidence. EI # 5 stated 3 of the vials were clearly tampered with but he/she decided it would be best to remove the fourth vial because he/she could not determine if the fourth vial had been tampered with.

The surveyor asked EI # 5, "What changes did the facility make to prevent this type of diversion from happening again?" EI # 5 stated, "The nurse was fired and the ABN was notified."

The surveyor asked EI # 5, "Did you discuss and document this incident in the facility Quality Assurance process (QA)?" EI # 5 stated, "No."

Review of the QA monthly meeting agenda dated 2/9/17 and 4/25/17 revealed no documented discussion, recommendation or resolution regarding the diversion of medication or near miss medication error. The facility's pharmacy services failed to report and take measures to identify, review, and prevent ways to minimize diversions, near miss, and medication errors in the facility's QA program.

An interview was conducted on 9/12/17 at 10:30 AM with EI # 5 who confirmed the above findings.

Based on review of facility policies and procedure, observations and interviews, it was determined the staff failed to document preventive maintenance inspection on all equipment in the Radiology Department. This had the potential to negatively affect all patient's served by this facility.

The findings include:

Title: Equipment Maintenance
Revised date: 12/15/16

"Policy:

To ensure patient safety and minimize equipment downtime, a program will be established to maintain both radiographic equipment and other biomedical equipment utilized in the Radiology Department. This program will provide for the monitoring and establishment of records which will provide a chronological history of equipment preventive maintenance and repair in order to maintain optimal operations..."

An observation of the Radiology Department was made on 9/13/17 at 11:00 AM. There were no Biomed Stickers or other documentation available to ensure the following Radiology equipment had been checked for hazards:

X-Ray Machine

CT (Computed Tomography) Machine

Ultrasound Machine

Mammography Machine

EKG (Electrocardiogram) Machine

During an interview with a Employee Identifier (EI) # 8, Radiology Manager on 9/13/17 at 11:15 AM, EI # 8 verified there were no Biomed stickers on the equipment and no preventive maintenance had been performed on the equipment listed above.

Based on review of facility policy and procedure, observation, and interview, it was determined radiation badges were not monitored according to facility policy. This had the potential to affect all patient's and staff.

Findings include:

Title: Personnel Radiation Exposure Monitoring
Policy Date: 11/18/10

"Policy:

Any person who enters a radiation area whose access is controlled or who is likely to recieve > (greater than) 10 % (percent) of a permissible limit, shall wear appropriate devices for measuring personnel exposure. These devices shall be provided by the Radiology Department.

Procedure:

... 4. Personnel monitoring devices employed for the purpose of monitoring radiation resulting from X-Ray radiation shall be changed monthly.

5. If a personnel exposure in excess of permissible limits is suspected to have occurred, the RSO (Radiation Safety Officer) should send the device to RDC (Radiation Detection Company) immediately so that the device may be processed to ascertain the individual's exposure level. An exposure evaluation will be performed by the RSO, who shall initiate corrective action to preclude recurrence of the event...

8. All film badges should be kept with a control film badge in a designated area, at all times, when an employee is not on duty. Film badges should never be worn off of the premises or while on duty at other facilities...

10. Radiation dosimetry reports are furnished each calendar month and are available for individual personnel's review..."

During a tour of the radiology department on 9/13/17 at 11:00 AM, the surveyor met with Employee Identifier (EI) # 8, Radiology Manager who provided the department's last radiology badge inspection results dated 7/2017. There were no documented results for the badges worn the month of 8/2017.

The surveyor asked EI # 8, "Where are the radiology badge results for 8/2017?" EI # 8 stated, "We are unable to obtain the results." EI # 8 logged onto the facility's account with Radiation Detection Company to show the surveyor there was a restriction on the account use due to non payment for the following outstanding invoices:

Date: 4/10/17, Invoice # 4583248, Amount 22.75

Date: 5/10/17, Invoice # 4598288, Amount 22.75

Date: 5/25/17, Invoice # 4605492, Amount 22.75

Date: 6/10/17, Invoice # 4612386, Amount 3.25

Date: 6/21/17, Invoice # AE63887, Amount -22.75

Date: 7/10/17, Invoice # 4622461, Amount 26.00

Date: 8/10/17, Invoice # 4631829, Amount 26.00

Date: 8/25/17, Invoice # 4636093, Amount 26.00

Further review of the invoice revealed the following documentation:

"Your account is on hold and functionality is restricted.

Balance: 126.75...

The last payment posted to your account was $(dollars) 22.75 on 6/21/17..."

On 9/14/17 at 11:26 AM EI # 8 stated, "The radiology badges were not resulted because they were not sent out to the vendor." The surveyor asked EI # 8, "Why were the badges being held at the facility?" EI # 8 stated, she/he has an employee off on vacation and he/she was waiting on the employee to return to work to get the employee's badge and sent all badges off at the same time." The facility failed to have access to the RDC for immediate results of employee radiation exposure and employee badges were not kept in a designated area per facility policy.

An interview was conducted on 9/14/17 at 11:26 AM with EI # 8 who confirmed the above 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 policy and procedures, manufacturers directions for use, observations, and interviews with the staff, it was determined the facility staff failed to ensure:

1) the facility policy and procedure for proper hand hygiene was followed.

2) patient rooms were cleaned and disinfected with products effective against Clostridium Difficile (C Diff).

3) monthly infection prevention tracking report included results of all gastrointestinal cultures positive for C Diff.

This did affect Medical Record (MR) # 7 and had the potential to negatively affect all patients served by the facility.

Facility Policy/Procedure Title: Hand Hygiene
Date Revised: 5/13

"Purpose:

To decrease the risk of transmission of infection by appropriate hand hygiene.

To ensure compliance with the current CDC (Centers for Disease Control) hand hygiene guidelines.

Policy:

Hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections...

I. Indications for handwashing and hand antisepsis

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


CDC-10 Cleaning and Disinfection

A Quaternary Disinfectant Cleaner compound featuring a clinging foam. Straight or Dilution: 12 oz. makes gallon. pH 11.5 - 12.3. USDA: C1; 4 per case. Kills HBV (Hepatitis B Virus), HIV-1 (AIDS Virus), Herpes simplex Type 2 and Influenza A3/Hong Kong viruses on hard nonporous inanimate surfaces. Ready to use, destroys germs faster than most competitive products which require 10 minute contact time. Effective against the following antibiotic-resistant bacteria: Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant Enterococcus faecalis (VRE). Surface safe, may be used on walls, partitions, vinyl, chrome, stainless steel, formica, fiberglass, porcelain, and ceramic.


During an observation of medication administration on 9/14/17 at 8:48 AM, the surveyor and EI (Employee Identifier) # 10, RN (Registered Nurse) exited the psychiatric unit to get medications for unsampled patients from another Omnicell medication cabinet located on the Medical and Detoxification unit.

EI # 10 entered the Omnicell medication cabinet and removed the following medications:

Diclofenac Na (Sodium) 75 mg (milligram)

Baclofen 10 mg X (times) 2 tablets (tab)

Diclofenac Na 75 mg EC (Enteric Coated) X 1 tab

Methocarbamol 500 mg X 1 tab

Digoxin 250 mcg (Microgram) X 1 tab

Neurontin 100 mg X 1 tab

EI # 10 failed to perform hand hygiene after touching inanimate objects (doors coming out of the psychiatric unit, and elevator button) before entering the Omnicell medication cabinet.

An interview was conducted on 9/14/17 at 11:47 AM with EI # 1, Chief Nursing Officer who confirmed the above findings.



39080

1. MR # 7 was admitted to the hospital on 6/2/17 with diagnoses including Low Blood Pressure, Acute Colitis, Mild Volume Depletion and Hypokalemia. The patient was discharged back to the SNF (skilled nurse facility) on 6/5/17.

Record review revealed an order on 6/2/17 for the collection of stool for C. Diff sent to Labcorp.

Review of LapCorp results revealed the specimen was collected on 6/2/17, received and entered at LabCorp on 6/3/17 and a positive result for C. Diff was documented and reported to the facility on 6/5/17 at 7:05 PM.

A notation on the lab results stated "Called to SNF staff at 7:10 AM on 6/6/17" by EI # 3, Quality Assessment (QA) & Performance Improvement (PI), Infection Control Practitioner (ICP), and Employee Health (EH) Registered Nurse (RN).

Review of facility Infection Control log revealed no tracking of the C. Diff infection.

On 9/14/17 at 11:50 AM, an interview was conducted with EI # 1, Chief Nursing Officer and EI # 3 who confirmed the above findings.



30952

In an interview on 9/14/17 at 12:12 PM, Employee Identifier (EI) # 3, Quality Assessment & Performance Improvement, Infection Control Practitioner, and Employee Health Registered Nurse, reported MR # 7's Clostridium Difficile (C Diff) result was reported to the transferring facility on 6/6/17 following the inpatient discharge on 6/5/17.

EI # 3 confirmed he/she could not be certain environmental services was notified the patient room was to be cleaned following a positive Clostridium Difficile culture result. EI # 3 reported environmental services would have cleaned with the product routinely used for terminal room cleaning.

The surveyor requested to see the terminal patient room cleaning product. EI # 3 presented a bottle of CDC (Clinging Disinfectant Cleaner)-10 Cleaning and Disinfection.

The product label did not contain documentation the CDC-10 was effective against Clostridium Difficile.

Review of June 2017 Infection Prevention Monthly Report documentation failed to include tracking of the 6/2/17 inpatient gastrointestinal culture positive for Clostridium Difficile.

In an interview on 9/14/17 at 1:30 PM, EI # 1, Chief Nursing Officer confirmed the above findings.

2. MR # 11 was admitted to the hospital on5/9/17 with the diagnoses including Severe Symptomatic Hypokalemia and Severe generalized weakness.

Review of the MR revealed the Discharge Planner failed to document discussions of home health choices with the patient and / or caregiver. Further review revealed the Choice Form/ Letter was not provided to the patient and/ or caregiver for review.

In n interview conducted on 9/14/17 at 112:00 PM with EI # 1who confirmed the aforementioned findings.


39080

Based on review of medical records, facility Choice Letter and interview, it was determined that in 2 of 2 records who was referred to a Home Health agency the facility failed to give the patients a choice of providers. This affected MR # 12 and # 11 and had the potential to negatively affect all patients served by this facility.

"Patient information and Choice letter

Your physician has recommended home health care after you leave the hospital.
...You have the right to select any home care agency to provide the care ordered by your physician....Regardless, it is your choice. If you do not select an agency, our Case Manager,...will assign you to our affiliated agency."

Findings include:

1. MR # 12 (add the admission date in the section please and was discharged home after receiving care for injuries sustained in a motor vehicle accident.

Review of the 5/8/17 physician's order revealed an order to DC(discharge) home to Home Health Services.

Review of the medical record revealed no discussion with the patient or caregiver regarding a preference of home health agencies.

Review of the medical record revealed no Patient Information and Choice Letter in the record.

An interview was conducted on 9/14/17 at 11:35 AM with Employee Identifier # 1, Chief Nursing Officer, who confirmed the discharge planner did not document that she supplied the patient a choice list to select a Home Health agency.