HospitalInspections.org

Based on a review of personnel records, facility policy review, OSHA (Occupational Safety and Health Administration ) Hepatitis B Vaccination Guidelines and interview, it was determined the facility failed to obtain documentation of Hepatitis B screening in 4 of 6 personnel records reviewed for the Outpatient Rehabilitation Clinic. This had the potential to effect all staff providing rehabilitation services.

Findings include:

OSHA
1910.1030(f)(2)
Hepatitis B Vaccination

1910.1030(f)(2)(i)
Hepatitis B vaccination shall be made available after the employee has received the training required in paragraph (g)(2)(vii)(I) and within 10 working days of the initial assignment to all employees who have occupational exposure unless the employee has previously received the complete hepatitis B vaccination series, antibody testing has revealed that the employee is immune, or the vaccine is contraindicated for medical reasons.

Subject: 109 Employee Vaccinations
Effective Date:10/1/99
Policy:
New employees will be given their initial tuberculin tests, Hepatitis B...
...3 Human Resource Department will schedule... appointments for Hepatitis B vaccinations...
3. It has been suggested as a preventative measure that all employees that provide patient care...complete the series...it is not a mandatory requirement and is optional...

In 4 of 6 Outpatient Rehabilitation Clinic employee personnel records reviewed, the facility failed to include documentation of Hepatitis B injections being offered to the employees, or documentation of immunity of Hepatitis B from previous injections.

An interview conducted on 3/14/13 at 3:08 PM, with EI # 6, Rehabilitation Clinic Manager, confirmed the above findings after submission of requested Hepatitis B employee documents.

Based on observations and interviews with facility staff, it was determined the Hospital failed to post written instructions informing emergency room patients of their right to file a complaint with the State Agency. This had the potential to affect all patients who presented to the Emergency Department (ED) for treatment.

Findings include:

During a tour of the ED on 3/12/13 at 1:00 PM the surveyor noted the toll free State Hot Line phone number for patients to call to voice grievances was not posted in the ED lobby, the triage rooms, the ambulance bay entrance or in the ED treatment rooms. The surveyor observed the posted Patient Rights in the ED lobby did not have the State Hot Line number listed.

On 3/12/13 at 1:12 PM the surveyor asked Employee Identifier (EI) # 9, ED Clerk, what forms the patients filled out when they presented to the ED for treatment. EI # 9 stated the patients fill out the Emergency Room Demographic Consent Form.

The surveyor reviewed the aforementioned form. The form contained the following documentation: "....I have read the above statement and agree to consent for treatment and have received .....a copy of the Patient Rights."

On 3/12/13 at 1:14 PM the surveyor asked EI # 9 if the patients are given a copy of the Patient Rights. EI # 9 stated that he/she does not give the patients a copy of the Patient Rights.

During an interview on 3/12/13 at 1:55 PM, EI # 2, Registered Nurse in the ED confirmed the Patient Rights posted in the ED lobby did not contain the State Hot Line number.

An interview on 3/14/13 at 1:45 PM with EI # 1, Director of Nursing, and EI # 10, Chief Executive Officer, confirmed the Patients Rights the surveyor observed posted in the ED on 3/12/13 did not have the State Hot Line number.

Based on review of medical records, facility policy and procedure review and interviews with administrative staff, it was determined in 2 of 5 medical records reviewed with wounds the nurse failed to:

1. Provide wound care as ordered

2. Document measurements of the wound and description of the wounds.

This affected medical record (MR) # 11 and MR # 13 and had the potential to affect all patients receiving wound care.

Findings include:

Facility Policy

Subject: Wound Care

Reviewed: 2/9/07

Standard of Care

The patient at risk for/or with skin breakdown may expect professionally managed and individualized care by qualified nursing staff, with ongoing assessment and intervention to maintain skin integrity, prevent skin breakdown, and promote healing of the skin...

Medical record findings include:

1. MR # 11 was admitted to the facility on 2/13/13 with a diagnoses of ORIF (Open Reduction Internal Fixation) of left tibia and fibula, End Stage Renal Disease, Chronic Obstructive Pulmonary Disease, Hypertension and Coronary Artery Disease.

The patient was admitted to Swing Bed status for rehabilitation per Physical Therapy.

Review of the Nursing Swing Bed Admission History Form dated 2/13/13 revealed the patient had a surgical wound to the left lower extremity with a dressing that was clean,dry and intact, Mepilex dressing to the coccyx area which was clean,dry and intact and a dressing to the right great toe which was clean,dry and intact.

Further review of the Nursing Swing Bed Admission History Form revealed an observation area for wound documentation for measurements, locations, and condition of the wound. Review of this form revealed that wounds were documented on the diagram with no documentation of the condition of the wounds or measurements of the wounds.

Review of the nurses notes dated 2/13/13 - 3/4/13 revealed documentation describing the dressing changes and did not contain a description of any of the wounds or wound measurements.

An interview Employee Identifier (EI) # 1, Director of Nursing, on 3/4/13 at 11:40 AM confirmed there was no documentation of the patient's wound measurements since admission.



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2. MR # 13 was admitted to the facility 10/12/12 to 10/19/12 with diagnoses including Possible Small Bowel obstruction, Probable Urinary tract Infection and History of Cerebrovascular Accident.

Review of the 10/13/12 physician's orders revealed wounds requiring wound care to the Right (R) and Left (L) trocanter wounds and the coccyx.

Review of the 10/12/12 nurse documentation revealed wound assessments to the 3 wounds above including wound description and wound measurements. There was no documentation for the specific wound care provided.

Review of the 10/13/12 to 10/19/12 nurse documentation revealed no documentation of wound assessments to include description of wound sites, periwound skin and wound drainage. There was no documentation of wound measurements for the week of 10/15/12 to 10/19/12.

An interview was conducted on 3/14/13 at 11:00 AM, with EI # 1, who validated the facility's lack of wound care/assessment documentation.

Based on observations, facility policy review and staff interview, it was determined the facility failed to ensure that all medications available for patient use in the facility were not expired. This had the potential to affect all patients at the facility.

Findings include:

Facility Policy

Policy Description: Expired Supplies/Medications

Effective Date: 10/01/2010

Policy: Bibb Medical Center monitors and disposes of expired medication and supplies according to the U.S. Food and Drug Administration (FDA) recommendations for disposal. Medications and supplies which have expired will have the packaging opened and the product will be rendered unusable if possible. The item is then placed in the trash or in the Biohazard closet as appropriate for the product.

4. Liquid medications may be placed in the locked Biohazard Disposal service.

1. A tour of the Emergency Department (ED) Exam Rooms 3A and 3B was conducted on 3/12/13 at 1:30 PM. During the tour the following outdated medications were observed:

(1) 100 milliliter (ml) bag of 0.9% Sodium Chloride expired 8/2012
(3) 1000 ml bags of Lactated Ringer and 5% Dextrose expired 2/2013

An interview conducted on 3/12/13 at 1:55 PM with Employee Identifier (EI) #2, the ED registered nurse (RN) confirmed the aforementioned findings.




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2. A tour of the Outpatient Therapy Clinic Wound Care treatment room was conducted on 3/13/13 at 8:35 AM. Six boxes of Hypafix dressing, 2 inch by 10 yards, with expiration date of 5/2006 were found in an upper cabinet. One specimen cup, not labeled or dated, that contained a small amount of yellow liquid was found in a bottom cabinet.

EI # 11, Rehab Aide, and EI # 4, Regional Rehab Program Manager, were present and validated the findings.

3. A tour of the Radiology Department was conducted on 3/13/13 at 10:35 AM. During the tour, the surveyor observed the following expired supply in the Emergency Drug Box: Sodium Bicarbonate 8.4 % 50 milliequivalent's/50 milliliters, expired 2/1/13. EI # 7, Radiology Department Head, notified the pharmacy and the expired Sodium Bicarbonate was replaced during the tour.

During the tour, a toothbrush and toothpaste were found in a cabinet where Gastrografin for patient use was being stored. EI # 7 promptly removed the personal hygiene items.

During the tour, a small refrigerator was observed in the Radiology Department. Barium Sulfate suspension and soft drinks for patient use with the Barium, as reported by EI # 7, Radiology Department Head, were observed in the refrigerator. A boxed meal, belonging to staff, was also observed in the refrigerator along with the Barium Sulfate and carbonated beverages for patient use.

An interview on 3/13/13 at 10:35 AM with EI # 7, confirmed the aforementioned findings.

Based on observations during the 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.

Findings were:

Refer to the Life Safety Code survey report for findings.

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

(1) All medical supplies available for patient use in the facility were not expired

(2) All supplies and equipment were maintained in a safe working environment.

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

Findings include:

Hot Packs-Clinical Practice Guideline
Effective Date: 8/1/5; Revision Date: 12/26/12
...Equipment:
1. The hot packs...will be kept in a thermostatically controlled cabinet in water between 154 and 166 degrees Fahrenheit...
2. With each use, the clinician will ensure that the water is clean and the temperature is within stated range. The hydrocollator will be cleaned every two (2) weeks and a cleaning log maintained...

Paraffin Bath-Clinical Practice Guideline
Effective Date: 6/1/5
...Equipment:
...4. The paraffin bath will be cleaned monthly and a cleaning log maintained.
5. The temperature will be checked daily whenever the unit is turned on and a log of these checks will be maintained...

Equipment Service Record
Revision Date: 9/1/6
Policy

The inspection of and service provided to each piece of equipment in the rehab department will be indicated on the Equipment Service Record...The form is initiated when equipment is placed into service. Any piece of equipment in need of repair will not be used until repairs are completed.

Procedure
1. Any equipment in need of repair will be red-tagged "DO NOT USE" and stored in a non-resident treatment area until repaired...

Equipment Management and Electrical Safety
Revision Date: 9/1/6
Policy
...All electrical equipment will be checked on an annual basis to assure proper mechanical and calibrated function capabilities.

Procedure
3...GFI's (ground fault interrupts) should be considered with whirlpools, paraffin baths...or any other electrical equipment that may come in contact with fluids...
10. Record all equipment inspections and service on the Equipment Service Record form.

1. A tour of Emergency Department (ED) exam rooms 3A and 3B was conducted on 3/12/13 at 1:30 PM. During the tour the surveyor observed the following expired supplies:

(1) 19 Gauge (GA) 1 inch Huber point Infusion Set expired 4/2011
(1) 16 French (FR) Foley catheter expired 10/2012
(1) 16 FR Foley catheter expired 11/2011
(3) 18 FR Foley catheters expired 10/2012
(1) 20 FR Foley catheters expired 11/2011
(1) 22 FR catheter expired 4/2011
(2) 24 FR Foley catheters expired 09/2010
(2) Purple top vacutainers expired 1/2013
(6) Blue top vacutainers expired 2/2013

An interview on 3/12/13 at 1:55 PM with Employee Identifier (EI) # 2, ED Registered Nurse, confirmed the aforementioned findings.



30952

2. A tour of the Outpatient Therapy Clinic was conducted on 3/13/13 at 8:35 AM. During the tour, the surveyor observed the following equipment in the exercise room that did not include preventive maintenance documentation:
1. 2 SCI FIT upper and lower extremity cycles
2. 1 SCI FIT Hoist 4400 Hi-Lo Pulley
3.1 SCI FIT Pulley
4. 1 Cateye lower extremity cycle
5. 1 Web Slide Exercise Slide
6. 1 upper extremity pulley (mirror placed in the middle of the pully)

A tour of the Outpatient Therapy Clinic Wound Care treatment room was conducted on 3/13/13 at 8:45 AM. The following equipment did not contain preventive maintance documentation:
One Hydrollator, one Whirlpool treatment tub, two Parafin baths and 1 COL PAC machine.

There was no cleaning log or temperature log for the 2 Paraffin baths.

The Hydrocollator cleaning schedule 2012 log documentation revealed no entries since 11/26/12. There were no entries for the months of January, February, June and July 2012.

The Hydrocollator Temperature Log presented the surveyor revealed the temperature readings of 160 degrees for 11/1/12 through 11/7/12.

The surveyor requested any other documentation regarding the preventive maintanence logs and cleaning schedules for rehab equipment. No additional documentation was provided on 3/13/13.

EI # 11, Rehab Aide, and EI # 4, Regional Rehab Program Manager, present during the tour, validated the above findings.

3. A tour of the Radiology CAT (Computer Axial Computer) scan room was conducted on 3/13/13 at 10:35 AM.

During the tour, a toothbrush and toothpaste were found in a cabinet where Gastrografin for patient use was being kept. EI # 7, Radiology Department Head. promptly removed the personal hygiene items.

During the tour, a small refrigerator was observed in the radiology department. Barium Sulfate suspension and soft drinks for patient use with the Barium, as reported by EI # 7, were observed in the refrigerator. A boxed meal, belonging to staff, was also observed in the refrigerator along with the Barium Sulfate and carbonated beverages for patient use.

An interview on 3/13/13 at 10:35 AM with EI # 7, Radiology Department Head, confirmed the aforementioned findings.

Based on observations, facility policy review and staff interview, it was determined the facility failed to ensure that all medications available for patient use in the facility were not expired. This had the potential to affect all patients at the facility.

Findings include:

Facility Policy

Policy Description: Expired Supplies/Medications

Effective Date: 10/01/2010

Policy: Bibb Medical Center monitors and disposes of expired medication and supplies according to the U.S. Food and Drug Administration (FDA) recommendations for disposal. Medications and supplies which have expired will have the packaging opened and the product will be rendered unusable if possible. The item is then placed in the trash or in the Biohazard closet as appropriate for the product.

4. Liquid medications may be placed in the locked Biohazard Disposal service.

1. A tour of the Emergency Department (ED) Exam Rooms 3A and 3B was conducted on 3/12/13 at 1:30 PM. During the tour the following outdated medications were observed:

(1) 100 milliliter (ml) bag of 0.9% Sodium Chloride expired 8/2012
(3) 1000 ml bags of Lactated Ringer and 5% Dextrose expired 2/2013

An interview conducted on 3/12/13 at 1:55 PM with Employee Identifier (EI) #2, the ED registered nurse (RN) confirmed the aforementioned findings.




30952

2. A tour of the Outpatient Therapy Clinic Wound Care treatment room was conducted on 3/13/13 at 8:35 AM. Six boxes of Hypafix dressing, 2 inch by 10 yards, with expiration date of 5/2006 were found in an upper cabinet. One specimen cup, not labeled or dated, that contained a small amount of yellow liquid was found in a bottom cabinet.

EI # 11, Rehab Aide, and EI # 4, Regional Rehab Program Manager, were present and validated the findings.

3. A tour of the Radiology Department was conducted on 3/13/13 at 10:35 AM. During the tour, the surveyor observed the following expired supply in the Emergency Drug Box: Sodium Bicarbonate 8.4 % 50 milliequivalent's/50 milliliters, expired 2/1/13. EI # 7, Radiology Department Head, notified the pharmacy and the expired Sodium Bicarbonate was replaced during the tour.

During the tour, a toothbrush and toothpaste were found in a cabinet where Gastrografin for patient use was being stored. EI # 7 promptly removed the personal hygiene items.

During the tour, a small refrigerator was observed in the Radiology Department. Barium Sulfate suspension and soft drinks for patient use with the Barium, as reported by EI # 7, Radiology Department Head, were observed in the refrigerator. A boxed meal, belonging to staff, was also observed in the refrigerator along with the Barium Sulfate and carbonated beverages for patient use.

An interview on 3/13/13 at 10:35 AM with EI # 7, confirmed the aforementioned findings.

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

(1) All medical supplies available for patient use in the facility were not expired

(2) All supplies and equipment were maintained in a safe working environment.

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

Findings include:

Hot Packs-Clinical Practice Guideline
Effective Date: 8/1/5; Revision Date: 12/26/12
...Equipment:
1. The hot packs...will be kept in a thermostatically controlled cabinet in water between 154 and 166 degrees Fahrenheit...
2. With each use, the clinician will ensure that the water is clean and the temperature is within stated range. The hydrocollator will be cleaned every two (2) weeks and a cleaning log maintained...

Paraffin Bath-Clinical Practice Guideline
Effective Date: 6/1/5
...Equipment:
...4. The paraffin bath will be cleaned monthly and a cleaning log maintained.
5. The temperature will be checked daily whenever the unit is turned on and a log of these checks will be maintained...

Equipment Service Record
Revision Date: 9/1/6
Policy

The inspection of and service provided to each piece of equipment in the rehab department will be indicated on the Equipment Service Record...The form is initiated when equipment is placed into service. Any piece of equipment in need of repair will not be used until repairs are completed.

Procedure
1. Any equipment in need of repair will be red-tagged "DO NOT USE" and stored in a non-resident treatment area until repaired...

Equipment Management and Electrical Safety
Revision Date: 9/1/6
Policy
...All electrical equipment will be checked on an annual basis to assure proper mechanical and calibrated function capabilities.

Procedure
3...GFI's (ground fault interrupts) should be considered with whirlpools, paraffin baths...or any other electrical equipment that may come in contact with fluids...
10. Record all equipment inspections and service on the Equipment Service Record form.

1. A tour of Emergency Department (ED) exam rooms 3A and 3B was conducted on 3/12/13 at 1:30 PM. During the tour the surveyor observed the following expired supplies:

(1) 19 Gauge (GA) 1 inch Huber point Infusion Set expired 4/2011
(1) 16 French (FR) Foley catheter expired 10/2012
(1) 16 FR Foley catheter expired 11/2011
(3) 18 FR Foley catheters expired 10/2012
(1) 20 FR Foley catheters expired 11/2011
(1) 22 FR catheter expired 4/2011
(2) 24 FR Foley catheters expired 09/2010
(2) Purple top vacutainers expired 1/2013
(6) Blue top vacutainers expired 2/2013

An interview on 3/12/13 at 1:55 PM with Employee Identifier (EI) # 2, ED Registered Nurse, confirmed the aforementioned findings.



30952

2. A tour of the Outpatient Therapy Clinic was conducted on 3/13/13 at 8:35 AM. During the tour, the surveyor observed the following equipment in the exercise room that did not include preventive maintenance documentation:
1. 2 SCI FIT upper and lower extremity cycles
2. 1 SCI FIT Hoist 4400 Hi-Lo Pulley
3.1 SCI FIT Pulley
4. 1 Cateye lower extremity cycle
5. 1 Web Slide Exercise Slide
6. 1 upper extremity pulley (mirror placed in the middle of the pully)

A tour of the Outpatient Therapy Clinic Wound Care treatment room was conducted on 3/13/13 at 8:45 AM. The following equipment did not contain preventive maintance documentation:
One Hydrollator, one Whirlpool treatment tub, two Parafin baths and 1 COL PAC machine.

There was no cleaning log or temperature log for the 2 Paraffin baths.

The Hydrocollator cleaning schedule 2012 log documentation revealed no entries since 11/26/12. There were no entries for the months of January, February, June and July 2012.

The Hydrocollator Temperature Log presented the surveyor revealed the temperature readings of 160 degrees for 11/1/12 through 11/7/12.

The surveyor requested any other documentation regarding the preventive maintanence logs and cleaning schedules for rehab equipment. No additional documentation was provided on 3/13/13.

EI # 11, Rehab Aide, and EI # 4, Regional Rehab Program Manager, present during the tour, validated the above findings.

3. A tour of the Radiology CAT (Computer Axial Computer) scan room was conducted on 3/13/13 at 10:35 AM.

During the tour, a toothbrush and toothpaste were found in a cabinet where Gastrografin for patient use was being kept. EI # 7, Radiology Department Head. promptly removed the personal hygiene items.

During the tour, a small refrigerator was observed in the radiology department. Barium Sulfate suspension and soft drinks for patient use with the Barium, as reported by EI # 7, were observed in the refrigerator. A boxed meal, belonging to staff, was also observed in the refrigerator along with the Barium Sulfate and carbonated beverages for patient use.

An interview on 3/13/13 at 10:35 AM with EI # 7, Radiology Department Head, confirmed the aforementioned findings.

Based on review of medical records, facility policy and procedure review and interviews with administrative staff, it was determined in 2 of 5 medical records reviewed with wounds the nurse failed to:

1. Provide wound care as ordered

2. Document measurements of the wound and description of the wounds.

This affected medical record (MR) # 11 and MR # 13 and had the potential to affect all patients receiving wound care.

Findings include:

Facility Policy

Subject: Wound Care

Reviewed: 2/9/07

Standard of Care

The patient at risk for/or with skin breakdown may expect professionally managed and individualized care by qualified nursing staff, with ongoing assessment and intervention to maintain skin integrity, prevent skin breakdown, and promote healing of the skin...

Medical record findings include:

1. MR # 11 was admitted to the facility on 2/13/13 with a diagnoses of ORIF (Open Reduction Internal Fixation) of left tibia and fibula, End Stage Renal Disease, Chronic Obstructive Pulmonary Disease, Hypertension and Coronary Artery Disease.

The patient was admitted to Swing Bed status for rehabilitation per Physical Therapy.

Review of the Nursing Swing Bed Admission History Form dated 2/13/13 revealed the patient had a surgical wound to the left lower extremity with a dressing that was clean,dry and intact, Mepilex dressing to the coccyx area which was clean,dry and intact and a dressing to the right great toe which was clean,dry and intact.

Further review of the Nursing Swing Bed Admission History Form revealed an observation area for wound documentation for measurements, locations, and condition of the wound. Review of this form revealed that wounds were documented on the diagram with no documentation of the condition of the wounds or measurements of the wounds.

Review of the nurses notes dated 2/13/13 - 3/4/13 revealed documentation describing the dressing changes and did not contain a description of any of the wounds or wound measurements.

An interview Employee Identifier (EI) # 1, Director of Nursing, on 3/4/13 at 11:40 AM confirmed there was no documentation of the patient's wound measurements since admission.



30952

2. MR # 13 was admitted to the facility 10/12/12 to 10/19/12 with diagnoses including Possible Small Bowel obstruction, Probable Urinary tract Infection and History of Cerebrovascular Accident.

Review of the 10/13/12 physician's orders revealed wounds requiring wound care to the Right (R) and Left (L) trocanter wounds and the coccyx.

Review of the 10/12/12 nurse documentation revealed wound assessments to the 3 wounds above including wound description and wound measurements. There was no documentation for the specific wound care provided.

Review of the 10/13/12 to 10/19/12 nurse documentation revealed no documentation of wound assessments to include description of wound sites, periwound skin and wound drainage. There was no documentation of wound measurements for the week of 10/15/12 to 10/19/12.

An interview was conducted on 3/14/13 at 11:00 AM, with EI # 1, who validated the facility's lack of wound care/assessment documentation.