HospitalInspections.org

Based on review of the personnel file, facility Nursing Competencies Checklist for Obstetrics (OB) Department: L & D (Labor and Delivery), WBN (Well Baby Nursery), PP (Post-Partum), medical records (MR), interviews with the facility staff, facility policies and procedures, it was determined the facility failed to ensure all competency skills specific to L & D/OB, and Surgical Services provided in the L & D/OB Department were completed.

This affected 1 of 1 employee files reviewed in the L & D/OB Department and did affect Employee Identifier (EI) # 10, L & D/OB RN. These deficient practices had the potential to negatively affect all patients served by the hospital.

Findings include:

Policy
Subject: Staff Orientation
Revised Date: 01/22/19

Procedure:

...Re-orientation of staff shall consist of, but not limited to:
...Continued annual competency evaluation to be done at yearly skills day.

1. Review of EI # 10's personnel file revealed a hire date of 3/15/17 as a L & D RN.
Review of EI # 10's personnel file, revealed a form titled "Nursing Competencies Checklist for Obstetrics Department: L & D, WBN, PP". There was no documentation the following Competency Skills on EI # 10 were completed since hire date of 3/15/17;

a. Lactation,
b. Pitocin and Cervidil,
c. Scrub C/S (Caesarean Sections),
d. Blood Admin (Administration),
e. NB (New Born) Assess (Assessment),
f. EES (Erythromycin Ethylsuccinate), Vit K (Vitamin K), Hep B Admin (Hepatitis B Administration),
g. Breast Feeding,
h. Heel Stick,
i. NB Screen, and
j. Hearing Screen.

An interview was conducted on 11/6/19 at 12:33 PM with EI # 11, Human Resources Director, who confirmed that he/she could not produce evidence at that time the competencies were completed.

Based on review of medical records (MR), policy and procedure, and interview with staff, it was determined the facility failed to ensure wound care was performed as ordered.

This affected 1 of 1 records reviewed with wounds, and did affect Patient Identifier (PI) # 16. This deficient practice had the potential to affect all patients treated at the hospital, with wounds.

Findings include:

Policy: Management and Care of Decubitus Ulcers
Date Revised: 2/19

...Purpose:
...2. To treat the existing ulcer and thereby provide care and comfort to the patient.

...Procedure:
...8. Use medications and perform dressings as prescribed by physician.

...Charting:
1. Date, time, and activities performed...

1. PI # 16 was admitted to the swing bed unit on 10/24/19 with diagnosis including Acute Urinary Tract Infection, Physical Deconditioning, and Recurrent Falls.

Review of the MR revealed the following order dated 10/24/19 at 11:30 AM: "...Stage 2 pressure ulcer to buttock- wash with NS (normal saline) and apply mepilex dressing, stage 2 to back wash with NS and apply dry 4 x 4 (gauze) with paper tape." There was no frequency ordered for the wound care.

Review of the MAR (Medication Administration Record) revealed an order was entered for the wound care to the mid back to be performed daily. There was no entry in the MAR for wound care to the pressure ulcer to the buttock.

Review of the Nursing Notes dated 10/24/19 at 10:51 AM to 11/1/19 at 1:20 PM revealed the nurse documented the following:

10/24/19 at 11:51 AM: "...Skin a stage 2 (1.0 x 0.5 x 0.2 CM (Centimeter) to rt (right) buttocks mepilex applied." There was no documentation the wound was cleaned with NS as ordered.

10/28/19 at 12:36 PM: "...received a bed bath and replaced Mepilex to gluteal area..." There was no documentation the wound was cleaned with NS as ordered.

10/30/19 at 6:00 AM: "...Mepilex removed from buttock due to being wet under it, due to incontinence. Moisture barrier applied and will be applied with each incontinence episode. Mepilex applied to upper back x 2 at site of draining cyst..." There was no documentation the wound was cleaned with NS as ordered. There was no order for a moisture barrier application. Mepilex was not ordered for the mid back wound.

During an interview on 11/6/19 at 8:24 AM with Employee Identifier # 3, RN (Registered Nurse), Nursing Supervisor, it was confirmed there was no frequency ordered for wound care, and wound care was not performed as ordered.

Based on observations, policy and procedure, and interview with staff, it was determined the hospital failed to ensure:

a) Multidose vials of medications were labeled per policy.

b) Patient's personal medications, including controlled medications, were sent home with family or the patient upon discharge.

c) Staff identified the patient prior to medication administration per policy.

This had the potential to affect all patients admitted to the hospital, and did affect 2 unsampled patients: 1 discharged patient, and 1 of 1 Labor and Delivery medication pass observations.

Findings include:

Policy: Medication- Dispensing and Administering Drugs
Date Revised: 12/3/18

...12. Patient is to be identified prior to administration of any medication....

...17. Maintaining Sterility of Multi-Dose Vials- Label vial date and time when opened. All vials are then to be discarded after discard time to prevent cross-contamination.

18. Insulins to be discarded after 28 days all other liquids to be discarded at expiration date.

Medication Administration:

...7. Prior to administration of medication, verification will be made by:
...c. Checking patient's armband.

...15. All medications brought to hospital by patient shall be:
a. Sent home with patient's family (may be placed in medicine cart drawer until family is available)...

1. During a tour of the medication room, located on the Medical Surgical unit, on 11/4/19 at 11:45 AM with Employee Identifier (EI) # 8, RN (Registered Nurse), the following was observed:

1- Multidose vial of Lidocaine 1 % (percent) 500 mg (milligrams)/ 50 ml (milliliters), opened and unlabeled with date opened.

1- Multidose vial of Novolin 70/30 insulin, 10 ml, opened and unlabeled with date opened, in the medication refrigerator.

On the floor of the medication room, beneath the shelves, was a plastic bag containing multiple bottles of prescription medications, including 1 bottle containing 23 tablets of Hydrocodone 7.5 mg/ 500 mg acetaminophen. The bottles were labeled with a patient name that was not on the current census. The bottles were filled by a local pharmacy in January 2019.

During an interview conducted with EI # 8, who was present during the tour, the above findings were confirmed. EI # 8 further stated the personal medications should have been sent home with the family or patient.




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2. An observation of medication administration for an unsampled patient was made on 11/6/19 at 9:28 AM by Employee Identifier (EI) # 10, Registered Nurse (RN) in the labor and delivery unit, LDRP (Labor, Delivery, Recovery, Postpartum) patient room #1.

EI # 10 failed to identify the patient by his/her armband prior to the medication administration per facility policy.

In an interview conducted 11/6/19 at 1:45 PM with EI # 1, Director of Nursing, the above findings were confirmed.

Based on observations, facility policies and procedures, Clorox Disinfecting Wipes directions for use, and interviews, it was determined the hospital staff failed to ensure:

1. Food was stored in a safe and sanitary manner.

2. The dishwashing machine temperature was checked during each use.

3. The hot water (temperature) was monitored and documented in the 3 compartment sink with each use.

4. Staff monitored food temperatures for meal service per facility policy.

5. Staff used the Clorox wipes according to manufacturer's instructions.

6. Staff performed hand hygiene after changing gloves.

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

Findings include:

Department: Dietary

Policy: Infection Control - All operations within the dietary department will follow the proper guidelines for infection control.
Date: None

C. Infection Control Practices:

6. Dishmachine final rinse will be 180 F (Fahrenheit), and documented on the log at each meal.

7. Pot washing sink will maintain the sanitizing sink at 171 F or chemical sanitizer will be used at the proper concentration, and this will be documented 3 times daily on the log.

9. Foods in original container must be dated.

D. Personnel:

1. ......Employees will follow the facility and department dress code.

7. Employees will follow proper handwashing procedures.

G. Food Preparation:

4. All potentially hazardous foods will be held at the appropriate temperatures according to the standards of regulating bodies.

Policy Title: Proper labeling of food items
Date: None

Procedures:

8. All labels must clearly identify what the date indicates, such as prepared on, frozen on, thawed on, use by, or opened.

Policy Title: Cleaning walk in cooler.
Date: None

Procedures: Weekly

2. Check dates on all items and discard if needed.

Policy Title: Proper use of Cook's Thermometer

2. Clean and sanitize the thermometer prior to use.

3. Use a disposable wipe to sanitize the stem of the thermometer before each use, after each use, and between each food item.

6. Never allow the head of the thermometer to touch the food.

Policy Title: Dishmachine Operation
Date: None

Procedures:

6. ....Send a few empty racks through the machine until final rinse reaches 180 F. The wash should be at least 150 F. Document these temperatures on the log.

Policy Title: Sanitation Sink Temperature
Date: None

Procedures:

1. Sanitation sink temperatures will be recorded three times per day.

b. Temperatures will be recorded daily before washing the dishes for each meal...

2. Proper temperature is greater than 180 degrees. This temperature must be reached before starting the sanitizing procedure.

Clorox Disinfecting Wipes

Directions for Use..."For surfaces that may come in contact with food, a potable water rinse is required. This product is not for use on dishes, glassware, or eating utensils...

Policy: Maintaining a Sanitary Tray Line
Date: 5/8/2017

Compliance Guidelines:

3. During tray assembly, staff should:

a. use gloves when handling food items
e. wash hands before and after wearing or changing gloves.
g. change gloves when activities are changed,...or when leaving the work station.

Findings include:

On 11/4/19 at 11:20 AM a tour was conducted of the hospital's dietary department with Employee Identifier (EI) # 15, Dietary Manager. The following observations were made:

1: Walk In Cooler:

- 8 cartons of strawberries were observed. 4 of the cartons contained berries with mold.

- an opened container of pickles had no label with either an open date or expiration date.

- an opened container of soy sauce had no label with either an open date or expiration date.

A repeat observation of the walk in cooler was made on 11/5/19 at 10:00 AM after the routine weekly cleaning and inspection of food items was performed on 11/4/19. EI # 12, Stock Supervisor, was present. The following observations were made:

- 2 cucumbers were stored loosely in a drawer observed with white mold on them.

- a single unopened bag of Romaine lettuce observed with pink coloring all around the edges of the lettuce. There was no date of expiration noted on the bag.

Pantry:

- an opened container of Knox gelatin powder with a use by date on the label of 10/13/19.

EI # 12, Stock Supervisor, present during observations of the walk in cooler and pantry, confirmed the above findings.

2. An observation of checking food holding temperatures by EI # 16, Dietary Aide, was conducted on 11/4/19 at 11:46 AM. Plating was then observed that began at 11:57 AM by EI # 17, Dietary Aide. The following observations were made:

The temperature probe was cleansed with a Clorox wipe before the initial use and between each food item checked. The probe was not rinsed prior to placing the probe in each food dish to check temperatures.

The entire length of the probe and part of the temperature probe handle came into contact with the mashed potatoes, chicken noodle soup, vegetable soup, tomato soup, baked beans, hot dogs, beef tips, and kraut. During the procedure, another Dietary Aide recording the food temperatures made EI # 16 aware the handle was touching the food. EI # 16 did not change practice and continued to allow the handle to come into contact with food items.

EI # 17 approached the plating area wearing gloves and hair net. EI # 17 touched personal eye glasses, door handle of refrigerator, and then plated one hot dog with bun. This hot dog was used for patient food service. When plating was ready to resume, EI # 17 removed gloves and donned another pair without performing hand hygiene, and then put on an apron.

EI # 17 failed to perform hand hygiene after removing gloves.

3. An observation of the 3 compartment sanitation sink utilized for washing pots and pans after meal service was conducted on 11/4/19 at 12:30 PM. This included review of documentation for daily sink temperatures May through October 2019. The following observations were made:

5/31/19 - no temperature recording for breakfast.
6/1/19 - no temperature recording for supper.
6/2/19 - no temperature recording for supper.
6/22/19 - no temperature recording for lunch.
6/27/19 - no temperature recording for supper.
9/1/19 - no temperature recording for lunch.
9/7/19 - no temperature recording for lunch.
9/13/19 - temperature recording for breakfast not legible.
9/17/19 - no temperature recording for supper.
9/20/19 - no temperature recording for supper.
9/27/19 - no temperature recording for lunch.
10/4/19 - no temperature recording for breakfast.

EI # 15 present with observation on 11/4/19 at 12:30 PM confirmed the above findings.

Review of documentation of daily temperature logs for wash and rinse temperatures of the dishmachine after each meal service, May through October 2019, revealed the following:

5/6/19 - recording for supper wash temperature was not legible.
6/17/19 - no wash or rinse temperatures recorded for lunch.
6/21/19 - no wash or rinse temperatures recorded for supper.
6/26/19 - no rinse temperature recorded for supper.
8/13-15/19 - rinse temperature recorded at 165 F for supper. Policy states temperature should be minimum 180 F.
9/8/19 - no wash or rinse temperatures recorded for lunch.
9/15/19 - recording for lunch was temperature was not legible.
10/18/19 - no rinse temperature recorded for lunch.
10/20/19 - rinse temperature recorded at 179 F for supper.

EI # 15 present with observation on 11/5/19 at 9:00 AM 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 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 and A- 724 for findings.

Based on observations, review of facility policy and procedure, Defibrillator and Crash Cart Shift Check Sheet and interviews with facility staff it was determined the facility failed to ensure defibrillators were checked daily.

Findings Include:

Subject: Crash Cart- Checking Of
Revised: 12/10/18

Policy:

1. All crash carts will be checked at the beginning of each shift daily to ensure that all emergency equipment is present and in proper working order...

Purpose: To ensure that all crash carts are properly stocked and in working order.

Procedure:

...2. Unplugging, charging, and firing of defibrillator on 200 joules, strip to be run daily and maintained in notebook.

...2. Daily shift check sheet to be initialed and signed on each shift daily ...

1. A tour of the Emergency Department was conducted on 11/4/19 at 11:13 AM.

At 11:20 AM the surveyor reviewed the (ER) Emergency Room Defibrillator and Crash Cart Shift Check Sheet for September 2019 and October 2019. Staff failed to document defibrillator strips on the following dates:

9/4/19, 9/8/19, 9/9/19, 9/14/19, 9/18/19, 9/20/19, 9/29/19, 9/30/19, 10/1/19, 10/2/19, 10/8/19, 10/9/19, 10/12/19, 10/15/19, 10/16/19, 10/19/19, 10/20/19, 10/25/19, 10/26/19, 10/28/19, 10/29/19, and 10/30/19.

An interview was conducted on 11/4/19 at 11:25 AM with Employee Identifier (EI) # 3, Registered Nurse (RN)/Nursing Supervisor, who was present during the review, confirmed there was no documentation of defibrillator strips on the above mentioned days.



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2. During a tour of the Medical Surgical floor on 11/04/19 at 3:30 PM, the surveyor reviewed the daily defibrillator checks for September and October 2019. Staff failed to document defibrillator strips on the following dates:

9/2/19, 9/3/19, 9/4/19, 9/5/19, 9/6/19, 9/8/19, 9/11/19, 9/13/19, 9/22/19, 10/23/19 and 10/24/19.

During an interview conducted on 11/4/19 at 3:30 PM with EI # 9, RN, who was present during the review, confirmed there was no documentation of defibrillator strips on the above mentioned dates.

Based on observations, Potter and Perry Fundamentals of Nursing, and interviews with facility staff, it was determined the facility failed to ensure staff provided a clean environment for medications prior to administration.

This did affect Patient Identifier (PI) # 21 and had the potential to negatively affect all patients served by this facility.

Findings include:

Potter and Perry Fundamentals of Nursing
6th edition
Chapter 34: Medication Administration page 847

Correct Administration ...For safe administration, the nurse uses aseptic technique and proper procedures when handling and giving medications.

1. An observation was conducted on 11/5/19 at 9:41 AM to observe Employee Identifier (EI) # 6, Registered Nurse (RN), perform a medication pass for PI # 21.

During the observation, EI # 6 placed the prepared medication insulin syringes in his/her uniform pocket (a dirty area). Prior to donning gloves to administer the insulin(s), EI # 6 placed the insulin syringes on the bed side table on top of patient's belongings thereby failing to maintain the prepared medications in a clean area prior to administration.

During an interview on 11/6/19 at 1:30 PM, EI # 3, RN/Nursing Supervisor, confirmed the above findings.

Based on review of the hospital policy, Association of Perioperative Registered Nurses, 2016 Guidelines for Perioperative Practice, observations, the hospital surgery services policy and procedure manual, and interview it was determined the hospital failed to ensure staff:

a) Monitored and documented temperature and humidity levels in the Central Sterile Supply (CSS) and Procedure room.

b) Followed their own policy and maintained complete surgical services policies and procedures.

These deficient practices have the potential to negatively affect all patients who require surgical procedures.

Findings include:

Policy Description: Policy Development and Approval
Effective Date: March 12, 2007

1. Purpose:

To provide a procedure for developing, reviewing, updating, and approving hospital policies.

2. Policy:

Hospital policies contain information relative to polices, programs, standards procedures, regulations, requirements, and other areas relative to overall hospital philosophy and operation.

Bibb Medical Center will maintain an up-to-date policy manual available to all staff members and must be complied "with'"by all facility personnel and its agents.

The following basic principles regarding hospital policy must be observed in order to assure an effective and efficient program:

1. Must be written in clear and concise language and reviewed at least annually by Department Director and Medical Staff.
2. New policies must be approved by the Department Director, CEO (chief executive office) and taken to Medical Staff for final approval.

2016 Guidelines for Perioperative Practice
Environment of Care, Part 2
page 270-272

Recommendation IV

The health care organization should create and implement a systematic process for monitoring HVAC (heating, ventilation, and air conditioning) performance parameters and a mechanism for resolving variances.

...The HVAC system is intended to reduce the amount of environmental contaminates...

Table 2: HVAC Design Parameters...

Preparation and packaging/clean workroom....Humidity maximum 60 %, Temperature 72 F (Fahrenheit) to 78 F...
Clean/sterile storage....Humidity maximum 60 %, Temperature 72 F to 78 F...
Procedure room....Humidity 20 % to 60 %, Temperature 70 F to 75 F...

A tour of the surgery services department was conducted on 11/4/19 at 10:36 AM with Employee Identifier (EI) # 13, Registered Nurse, ED (Emergency Department)/CSS. The surveyor observed 2 autoclaves and a metal shelf that contained multiple sterile packs in CSS. In addition to the 1 (one) Operating Room suite, there was a Procedure room in which cataract removals were performed. The surveyor requested to review the 2019 temperature and humidity logs for all surgical service areas. EI # 13 stated she/he did not think there was a thermometer in the CSS department and Procedure room.

There was no documentation staff monitored temperature and humidity in the CSS and Procedure room. There was no policy and procedure for monitoring the temperature and humidity in the CSS and Procedure room.

On 11/5/19 at 2:45 PM, the surveyor requested all surgical services, CSS, and anesthesia policies and procedures from EI # 3, Nursing Supervisor. EI # 3 stated "we are working on getting them together."

Review of the above policies and procedures provided to the surveyor on 11/6/19 at 10:55 AM revealed no policy and procedure for monitoring the temperature and humidity in the CSS area.

Review of the L&D (labor and delivery) Policy and Procedure Manual (reviewed 5/10/19 by the Department Director and Medical Staff), the surgical services, anesthesia policies and procedures provided on 11/6/19 at 10:55 AM included a "Cataract Policy and Procedure Manual", "Anesthesia Department" polices, "Disinfection/Sterilization of Instruments Policy and Procedure".

There was no documentation of the last annual review by the Department Director and Medical Staff on the "Cataract Policy and Procedure Manual", and the "Disinfection/Sterilization of Instruments Policy and Procedure policy manuals.

Further review of the above documents revealed no policy or procedure for resuscitative procedures/DNR (do not resuscitate) status during surgical procedures, no policy for Malignant hypothermia, no policy for OR safety practices including patient identification procedures, acceptable OR attire, and handling biomedical/medical waste.

The surgery services policies and procedures were not all inclusive. The Disinfection and Sterilization of Ophthalmic Instruments did not include an effective date/ approval date.
EI # 3 stated "it has not gone through medical staff yet".

Review of the document titled,"Disinfection and Sterilization of Instruments" revealed the document was in accordance with the CDC (Centers for Disease Control) and manufacturer's guidelines for cleaning/decontamination, packaging, sterilization, autoclave operation and biological indicators.

However, the document was not written in policy and procedure format. There was no effective date/approval date documented.

There was no policy regarding Flash Sterilization, whether it was an accepted hospital practice or not allowed.

During an interview conducted on 11/6/19 at 1:45 PM, EI # 1, Director of Nursing, confirmed the above findings.

Based on observation and interviews, it was determined the hospital failed to ensure equipment required for patient safety was available for use in the OR (operating room). This had the potential to affect all patients that utilized the surgery services and included OB (obstetric) patients requiring Cesarean Sections (C-section) and patients seeking cataract removal.

Findings include:

On 11/5/19 at 2:00 PM, a tour and observation of the surgery department was conducted with Employee Identifier (EI) # 13, Registered Nurse, ED (emergency department)/Central Sterile Supply. The surveyor requested to see the department tracheotomy set. EI # 13 reported "we had one and it went out of date."

During an interview on 11/6/19 at 9:40 AM and tour of OR # 1 used for C-section deliveries, EI # 13, Certified Registered Nurse Anesthetist, confirmed he/she was aware there was no tracheotomy tray in the OR.

In addition, there was no facility policy regarding emergency equipment available for the OR.

In an interview on 11/6/19 at 1:45 PM, EI # 1, Director of Nurses/OR Supervisor confirmed the aforementioned findings.

Based on review of the hospital OR (operating room) log documentation, the L&D (labor and delivery) Delivery Room Register documentation, L&D department policies and surgical services policies, the facility failed to ensure:

1) There was a policy for completion of all required operating room register/OR log documentation.

2) Staff completed all required documentation on the OR register or equivalent which included inclusive or total time of the operation, name of nursing personnel who performed scrub duties, name of the nursing personnel who performed circulating duties, patient age, pre and post-op diagnoses.

Findings include:

On 11/4/19 at 10:27 AM, a tour of the L&D unit was conducted with Employee Identifier (EI) # 10, L&D, RN (Registered Nurse). EI # 10 reported C-Section (Cesarean Section) deliveries occur in OR # 1 ("Section Room").

A tour of the hospital surgical services which included OR # 1, the Procedure Room 1 (cataract removal procedure room), PACU (post acute care unit) was conducted on 11/5/19 at 2:00 PM with EI # 13, RN, Emergency Department/CSS. EI # 13 provided the surveyors with the surgery service OR log documentation.

Review of the 2019 OR log documentation failed to include any C-section deliveries.

In an interview on 11/6/19 at 8:20 AM in L&D unit, EI # 10 reported there was an OR log on the L&D unit, however the L&D staff did not complete the OR log, instead documented C- Section deliveries in the Delivery Room Register.

Review of the 8 deliveries by C Section from May 2019 to October 2019 documented on the L&D Delivery Room Register failed to include the inclusive or total time of the operation, name of nursing personnel specific for the scrub and circulating duties, the pre and post-op diagnosis and the patient age.

The Delivery Room Register documentation completed by L&D staff was not complete for all required OR register items.

In an interview on 11/6/19 at 1:45 PM, EI # 1, Director of Nurses confirmed the above findings.

Based on review of the hospital policy, the Anesthesia Department policies and procedures, and interviews, it was determined the policies and procedures failed to include anesthesia service policies for delivery of care which addressed:

1. Infection prevention and control measures.

2. Safety practices in all anesthetizing areas.

3. Equipment monitoring inspection, testing and maintenance of anesthesia equipment.

4. Resuscitative protocols, emergency response including management of Malignant hyperthermia.

5. Reporting requirements.

Findings include:

Policy Description: Policy Development and Approval
Effective Date: March 12, 2007

1. Purpose:

To provide a procedure for developing, reviewing, updating, and approving hospital policies.

2. Policy:

Hospital policies contain information relative to polices, programs, standards procedures, regulations, requirements, and other areas relative to overall hospital philosophy and operation.

Bibb Medical Center will maintain an up-to-date policy manual available to all staff members and must be complied (with) by all facility personnel and its agents.

The following basic principles regarding hospital policy must be observed in order to assure an effective and efficient program:

1. Must be written in clear and concise language and reviewed at least annually by Department Director and Medical Staff.

2. New policies must be approved by the Department Director, CEO (chief executive office) and taken to Medical Staff for final approval.

On 11/5/19 at 2:45 PM, the surveyor requested all anesthesia policies and procedures from EI (Employee Identifier) # 3, Nursing Supervisor. EI # 3 stated "we are working on getting them together."

During an interview on 11/6/19 at 9:40 AM, EI # 14, Certified Registered Nurse Anesthetist, was asked what type surgical services were performed and the anesthesia types provided? EI # 14 reported current procedures were cataract removal using anesthesia, Versed/Fentanyl and Propofol, which were performed in the Procedure room and deliveries by C Section, with epidurea/spinal and general anesthesia which were performed in OR # 1.

The surveyor asked what was the policy for DNR's (do not resuscitate) during surgical procedures? EI # 14 stated "we follow Alabama State Law and a DNR status is resended during a surgical procedure." The surveyor asked EI # 14 for the hospital anesthesia policy and procedure manual. EI # 14 stated "we use the Cahaba Foundation polices (anesthesia services contract group) and they are working to get them together for you."

During the 11/6/19 9:40 AM interview, the surveyor asked EI # 14 where C Section deliveries recover after delivery? EI # 14 stated in the L&D suites. On 11/6/19 at 10:15 AM, EI # 14 identified the surgery services Malignant Hyperthermia kit, which included 36 vials of Dantolene and also a Lipid Rescue kit which was located in the Nursery Holding room.

Review of the anesthesia policies and procedures provided on 11/6/19 at 10:55 AM, labeled "Anesthesia Department" included the following policies:

1. Subject: Anesthesia Department, Effective Date 10/15

2. Subject: Anesthesia Coverage, Effective Date 10/15

3. Subject: Documentation, Effective Date 10/15 (and included individual medical record documents, the preanesthesia evaluation, the anesthesia preoperative assessment, a request and authorization for the administration of anesthesia, CPT (current procedural terminology), the anesthesia intraoperative record, an OB (obstetric) epidural anesthesia record, physician orders titled, "OB anesthesia pre-procedure orders with epidual/spinal meds (medications)".

4. Anesthesia Privileges

5. BLS/CPR (basic life support/cardiopulmonary resuscitation requirements), Revision date 11/29/07

There was no documentation of the last annual review by the Department Director and Medical Staff for the anesthesia policy manual provided.

Further review of the anesthesia policies and procedures revealed no policy or procedure for DNR status, Malignant hyperthermia, the use of the Lipid Rescue Kit following an epidural complication, infection control, equipment inspection/monitoring, and OR (operating room) safety practices.

During an interview conducted on 11/6/19 at 1:45 PM, EI # 1, Director of Nursing, confirmed the above findings.

Based on review of facility policy, medical records (MR's), and interview with facility staff, it was determined the facility failed to ensure the Emergency Department (ED) staff followed its own policy on Abuse /Neglect.

This did affect Patient Identifier (PI) # 6, 1 of 2 ED records reviewed for complaints of "altercation - alleged assault" and had the potential to negatively affect all patients who were treated in the ED with a complaint of "altercation - alleged assault."

Findings include:

Facility Policy: Abuse/Neglect
Reviewed: 2/19

Abuse Criteria:

Bibb Medical Center shall use the following criteria when completing assessments of patients who may be the victims of abuse. The presence of any one or more criteria does not necessarily prove abuse, but triggers further assessment or intervention.

Physical Assault:

1. Bruises, wounds, or burns ...

Domestic Abuse:

1. Bruises, wounds or burns:
a. Which the patient states have been inflicted by a spouse or significant other.

Responsibilities:

Employee Responsibilities and Initial Notification Procedure:

Documentation in the form of Quality Assurance reports, progress notes, or written statements are to be completed...

Other agencies and organizations may also have obligations to investigate allegations of abuse or neglect. These include local, state and federal law enforcement agencies.

Reporting:

1. A Licensed Health Care Professional shall notify the appropriate authorities immediately ... of all cases of suspected abuse/neglect.

1. PI # 6 was admitted to the ED on 8/3/19 with a chief complaint of "altercation - alleged assault".

Review of the ED nursing brief assessment revealed, "assault today by boyfriend - denies calling police - pain in face, neck, right shoulder, hip and wrist".

There was no documentation the local law enforcement (police) was notified of the alleged assault as directed per the facility policy.

An interview was conducted on 11/6/19 at 7:58 AM with Employee Identifier # 3, Registered Nurse/Nursing Supervisor, who stated, "The nurse notified the police, but failed to document it."

Based on review of medical records (MR), policies and procedures, and interviews with staff, it was determined the hospital failed to ensure staff in the rehabilitation (rehab) department notified the physician of changes to the patient's plan of care, and documented missed visits according to policy.

This affected Patient Identifier (PI) # 18 and PI # 19, 2 of 2 outpatient rehab records reviewed and had the potential to negatively affect all patients treated in the outpatient rehab department.

Findings include:

Policy: Outpatient Rehabilitation Services
Date Revised: 2/25/13

Policy:

...2. All patient visits will be documented in writing or via electronic documentation with electronic signature, in the patient's record. Proper documentation of communications with the referring physician should be maintained in the patients permanent medical record and will include the physician's signature when possible.

Documentation Requirements

1. Any cancellations or missed appointments will be documented (in the) communication log and will include the reason for the missed treatment, if provided.

Initial Evaluation and Assessment of the Patient

...5... The patient will participate in the development of the treatment plan, and the proposed plan of care will be mutually agreeable to the patient and clinician... The referring physician will sign the plan of care.

6. The orders contained on the prescription from the referring physician will be followed...

Updated Plan of Care

1. The updated plan of care is designed to exhibit the patient's overall progress and overall response to the initial treatment plan and justifies the continuance of the established treatment plan or the necessity for a change in the initial treatment plan.

2... Any changes in the treatment plan will be made by the treating therapist...

3. Each updated plan of care will include, at a minimum:
...v) Necessity to modify treatment plan.
vi) Frequency and anticipated duration of treatment yet needed.
...viii) Signature of physician.

Policy: Missed Patient Visits
Date Revised: 2/25/13

Purpose:

To outline the policy for appropriate documentation of a patient's missed visit, where the missed visit will affect the frequency of visits outlined in the plan of care.

Procedure:

In the event of a purposeful missed visit by a patient with a prescription for therapy, the therapy coordinator or treating clinician must document the case in the patient's medical record/ communication log...

1. PI # 18 was admitted for outpatient rehab on 9/18/19 with diagnoses including Pain in Left Knee and Low Back Pain.

Review of the Physical Therapy Plan of Care, dated 9/18/19, revealed an ordered frequency/ duration of 3 times a week for 4 weeks.

Review of the MR revealed two treatments the week of 10/27/19 and not three as ordered. There was no documentation of a missed visit or communication log for the patient, per policy.

During an interview on 11/5/19 at 9:30 AM with Employee Identifier (EI) # 7, Director, Outpatient Therapy, the above findings were confirmed.

2. PI # 19 was admitted for outpatient rehab on 10/15/19 with diagnosis including Pain in Right Shoulder, and Muscle Weakness (Generalized).

Review of the Physical Therapy Plan of Care, dated 10/15/19, revealed an ordered frequency/ duration of 3 times a week for 4 weeks.

Review of the MR revealed two visits the week of 10/20/19, and two visits the following week of 10/27/19, not three as ordered.

The surveyor requested documentation of patient contact for missed visits, or documentation of an updated plan of care. EI # 7 stated there was none.

An interview was conducted on 11/5/19 at 9:30 AM with EI # 7, who confirmed the rehab department failed to document missed visits, and notify the physician of changes in the plan of care.

Based on observation, review of medical records (MR's), facility policies and procedures and interviews, it was determined the facility to ensure staff performed activities assessments or developed an activities plan of care in 2 of 3 patients reviewed who were admitted to the swing bed unit.

This did affect Patient Identifier (PI) # 21 and PI # 22 and had the potential to negatively affect all patient's admitted to the swing bed unit.

Findings include:

Facility Policy: Interdisciplinary Team Process

Policy:

The program will have an identified Interdisciplinary Team (IDT) to ensure a comprehensive approach to the patient medical and/or rehabilitation needs ...

Team Members may include:

Care Manager/Social Worker
... Nurse Manager or designee

Procedure:

1. Each discipline will complete a discipline specific admission assessment ... within 4 to 48 hours of admission based on the discipline.

2. The Care Manager will complete a discharge planning assessment ... to ensure a comprehensive approach to identifying the patient's specific needs.

Facility Policy: Activity Program

Policy:

The facility provides for daily activities but mostly on an individual basis ...

The Activity Director/Social Service Designee is designated as the activity coordinator responsible to see that patient's needs are met ...

Procedure:

1. The care manager will assess their activity preferences during the Discharge Planning Assessment.

...4. Bibb Medical Center Activity staff will assess patient's activity preferences on admission ... and offer activities to patients.

1. During a tour of the swing bed unit on 11/5/19 at 8:00 AM the surveyor asked Employee Identifier (EI) # 3, Registered Nurse (RN)/Nursing Supervisor, where the activities calendar was posted. EI # 3 stated, "It is usually up there (pointing to the bulletin board") There was no calendar of activities posted on the swing bed unit. EI # 3 then stated, "But they (Social Services) comes in each day and goes over the calendar with the patient and leaves the calendar in the room with the patient."

A review of the swing bed census sheet submitted to the surveyors on 11/5/19 revealed PI # 21 and PI # 22 were admitted to the swing bed unit on 11/1/19.

On 11/5/19 at 8:04 AM the surveyor proceeded to PI # 21 and PI # 22's room. There were no calendars in PI # 21 and PI # 22's room. The surveyor asked PI # 21, "What activities he or she had been offered since admission?" PI # 21 stated, "None".

At 8:08 AM EI # 4, Activities Assistant (AA) and EI # 5, AA were rounding on the swing bed unit. The surveyor asked EI # 4 what was the timeframe for patient's to be assessed and offered activities on the swing bed unit. EI # 4 stated, "2 business days." The surveyor then asked EI # 4 what date PI # 21 and PI # 22 had been assessed, offered activities and a plan of care developed? EI # 4 stated, "We were just coming to assess them, but we don't develop a plan of care." The surveyor then asked if PI # 21 and PI # 22 were assessed and offered activities per policy and EI # 5 stated, "No."

2. PI # 21 was admitted to the swing bed unit on 11/1/19 with diagnoses including Wound to Left Heel, Diabetes Mellitus-Type 2, and Hypertension.

Review of the MR on 11/5/19 at 8:10 AM, which was 4 days after admission, revealed there was no documentation an activities assessment or activities plan of care had been completed on PI # 21.

The activities staff failed to document an activities assessment or activities plan of care within 48 hours of admission as directed per the facility policy on PI # 21.

An interview was conducted on 11/6/19 at 8:12 AM with EI # 3, who verified the aforementioned findings.

3. PI # 22 was admitted to the swing bed unit on 11/1/19 with diagnoses including Congestive Heart Failure (CHF), Diabetes Mellitus, and Atrial Fibrillation.

Review of the MR on 11/5/19 at 8:11 AM, which was 4 days after admission, revealed there was no documentation an activities assessment or activities plan of care had been completed on PI # 22.

The activities staff failed to document an activities assessment or activities plan of care within 48 hours of admission as directed per the facility policy on PI # 22.

An interview was conducted on 11/6/19 at 8 :00 AM with EI # 3, who verified the aforementioned findings.

Based on review of medical records (MR's), facility policy and procedure and staff interviews, it was determined the facility failed to ensure therapy evaluations/comprehensive assessments were completed per the facility policy.

This did affect 3 of 3 patient reviewed admitted to the swing bed unit, including Patient Identifier (PI) # 21, PI # 22 , PI # 16 and had the potential to negatively affect all patients admitted to the swing bed unit.

Findings Include:

Facility Policy: Interdisciplinary Team Process

Policy:

The program will have an identified Interdisciplinary Team (IDT) to ensure a comprehensive approach to the patient medical and/or rehabilitation needs ...

Team Members may include:

Care Manager/Social Worker
Therapists (PT/OT/SLP) {Physical Therapy/Occupational Therapy/Speech Language Pathology)
... Nurse Manager or designee

Procedure:

1. Each discipline will complete a discipline specific admission assessment ... within 4 to 48 hours of admission based on the discipline.

1. PI # 21 was admitted to the swing bed unit on 11/1/19 with diagnoses including Wound to Left Heel, Diabetes Mellitus-Type 2, and Hypertension.

Review of the MR revealed physician admission orders signed and dated 11/1/19 for PT/OT/ST (Speech Therapist) to evaluate and treat...

Review of the document titled "Occupational Therapy Plan of Care" revealed an initial OT assessment dated 11/4/19, which was 3 days after the admission date.

Review of the document titled "Speech Therapy Plan of Care" revealed an initial ST assessment dated 11/4/19, which was 3 days after the admission date.

An interview was conducted on 11/6/19 at 8:12 AM with Employee Identifier (EI) # 1, Director of Nursing, and EI # 2, Registered Nurse/Nursing Supervisor, who verified the aforementioned findings.

2. PI # 22 was admitted to the swing bed unit on 11/1/19 with diagnoses including Congestive Heart Failure (CHF), Diabetes Mellitus, and Atrial Fibrillation.

Review of the MR revealed physician admission orders signed and dated 11/1/19 for PT/OT/ST to evaluate and treat...

Review of the document titled "Occupational Therapy Plan of Care" revealed an initial OT assessment dated 11/4/19, which was 3 days after the admission date.

Review of the document titled "Speech Therapy Plan of Care" revealed an initial ST assessment dated 11/4/19, which was 3 days after the admission date.

An interview was conducted on 11/6/19 at 8:00 AM with EI # 1 and EI # 2 who verified the aforementioned findings.



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3. PI # 16 was admitted to the swing bed unit on 10/24/19 with diagnosis including Acute Urinary Tract Infection, Recurrent Falls, and Physical Deconditioning.

Review of the MR revealed an order for Speech Language Pathology, evaluate and treat... dated 10/24/19 at 11:30 AM.

Review of the document titled "Speech Therapy Plan of Care" revealed an initial ST assessment dated 10/28//19, which was 4 days after the admission date.

An interview was conducted on 11/6/19 at 8:24 AM with EI # 3, who confirmed the above findings.