HospitalInspections.org

Based on observations, facility policy and interviews, it was determined the hospital failed to ensure:

1. expired medications and supplies were not available for patient use a
2. multi-dose medications were initialed and dated when opened. This had the potential to affect all patients served by this facility.

The findings include:

Policy: Medication Administration Guideline
Revised Date: 03/18

Length of Use of Multidose Vials:
1. The use of multi-dose vials of medications...the expiration date for the affected medication will be 28 days from the day the vial is opened...
2. Multi-dose vials...that are opened by personnel will be labeled with the date opened and the initials of the person opening the vial...

1. A tour of the Emergency Department (ED) was conducted on 6/25/19 at 11:30 AM with Employee Identifier (EI) # 5, ED Registered Nurse.

In the medication preparation area the surveyor observed

a. Two opened and unlabeled multi-dose vials of Lidocaine 1%

b. Two opened and unlabeled bottles of Betadine solution

c. One opened and unlabeled bottle of Hydrogen Peroxide 3%

d. One opened bottle of alcohol 70% solution labeled with the open date 3/27/19 which remained available for patient more than 28 days after opening.

The above findings were verified with EI # 5 during the tour of the ED.

An interview with EI # 1, Director of Patient Care Services, on 6/27/19 at 10:50 AM confirmed opened vials/bottles are to be labeled when opened and expire in 28 days.

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 affect all patients served by the hospital.

Findings include:

Refer to Life Safety Code violations for findings.

Based on review of the facility's policies and procedures, medical records (MR) and interview with staff, it was determined the facility failed to:

1. Assess wounds to include wound measurements and document findings on 2 of 2 records reviewed of patients with wounds including MR # 2 and MR # 5.

2. Follow its own policy for Suicide Prevention/Precaution for 1 of 1 Emergency Department (ED) record reviewed with Suicide Ideation including MR # 13.

This deficient practice had the potential to negatively effect all patients with wounds and all patients at risk for suicide cared for by this facility.

Findings include:
Subject: Wound Treatment Policy
Reference: NUR 2806
Revised: 03/18

Policy:
Each patient will have a skin assessment and treatment plan for the maintenance of skin integrity and wound management if required. ...

Procedure:

2. The nursing staff will monitor the wound daily and assess for any signs of other skin breakdown.

3. Documentation will reflect assessment results and treatment plans.

Measuring Wound To Improve Outcomes
Resources: Association for Advancement of Wound Care Guidelines (AAWC) Rockville, Maryland, National Clearing House, Healthcare Research and Quality 2010

Wound measurement is the only evidence-based predictor of wound healing.

Wounds must be assessed and monitored to detect important changes, quantify progress, and guide treatment decisions. Assessment covers a variety of variable, such as amount of exudate, ... size of the wound

Measuring wounds: Because it is the change - not the actual area - that is important in clinical practice, it's essential to measure wound consistently.

The percentage of a reduction in wound size after two to four weeks is a significant and often independent, predictor of healing.

Policy: Suicide Prevention/Precaution
Revised Date: 03/18

Emergency Department

Purpose:
To guide the Emergency Department patient care staff in the identification and expeditious triage of individuals at risk of suicide/self harm.

Procedure
Any Emergency Department patient will be placed on suicide precautions if the patient is deemed to be an immediate risk for self-harm through the verbalization of self-destructive thoughts or feelings...

H. Level of risk will be reassessed at least every 2 hours by the ED physician until transfer takes place from the ED to a behavioral health unit.


1. MR # 2 was admitted to the facility on 5/16/19 with the diagnoses including Kidney Cancer and Decubitus Back With Cellulitis.

Review of

Review of the physician's orders dated 5/17/19 was to apply "Polymem to area of skin disruption on upper back ". Change every 3 days.

Review of the nurses notes dated 5/17/19, 5/19/19, 5/20/19 and 5/21/19 revealed no documentation the wound was measured, assessed and care provided.

An interview conducted on 6/27/19 at 11:42 AM with Employee Identifier (EI) # 1, Director of Patient Care Services who confirmed the above mentioned findings.

2. MR # 5 was admitted to the facility on 7/11/18 with a primary diagnosis of Generalized Weakness.

Review of the Admission Note dated 7/11/18 at 3:41 PM (afternoon) revealed the presence of a Stage II decubitus on the sacral area measuring 1.3 cm (centimeters) X 1 cm X > (less than) 0.1 cm. Further documentation revealed there was drainage from the sacral decubitus. There was no documented description of the drainage from the sacral decubitus.

The RN (Registered Nurse) documented on 7/11/18 at 3:41 PM revealed the presence of abrasion to the left elbow measuring " approximately 3 cm x 3 cm x >0.1 cm and a healing skin tear to top of left hand with approximate measurement of 2.5 cm.

Review of the RN note on 7/15/18 dressing was changed on the left elbow and measured. The RN documented "with drainage noted" but there was no documentation the sacral decubitus/ wound was assessed / measured.

Review of the RN note on 7/19/18 revealed the patient requested dressing change on the left elbow including linen change due drainage from the elbow. There was no documentation of the appearance of the wound and drainage and the dressing provided.

An interview was conducted with EI # 1 at 11:15 AM who confirmed the above mentioned findings.



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3. MR # 13 was admitted to the ED on 4/23/19 at 10:13 AM with diagnoses including Suicidal Ideation. MR # 13 was transferred from the ED to another facility on 4/24/19 at 2:19 AM.

Review of the ED record revealed documentation by the nurse at 10:18 AM the patient (pt) was hearing voices telling him/her to harm self...pt belongings placed outside of the room...pt in view of RN...

At 10:35 AM the nurse documented Suicide Risk Assessment (no total score documented), physician notified. Initiated suicide precautions per hospital policy for care of the suicidal patient.

There was no documentation the patient remained in view of the nurse, or that the patient was being monitored by 1:1 (one to one) observation. A tour of the ED department on 6/25/19 at 11:30 AM revealed the view of the ED bays were blocked by the desk when sitting at the nurses station of the Emergency Department.

The next Suicide Risk Screening was documented by the nurse at 11:09 PM.

There was no documentation the ED physician assessed the level of suicide risk every 2 hours until transfer as directed by the facility policy.

An interview conducted on 6/27/19 at 11:00 AM with EI # 1 confirmed the above findings.

Based on review of the facility's policies and procedures, medical records (MR) and interview, the facility failed to ensure records and forms are completed and authenticated on:

1. 1 of 1 death record reviewed including MR # 6

2. 7 of 8 Emergency Department (ED) transfer records reviewed including MR # 8, # 11, # 13, # 16, # 20, # 26 and # 27.

This deficient practice had the potential to negatively affect all patient's records at the facility.

Findings include:

Number: MR- 507 Death Certificates
Origination Date: 2/2012

I. Purpose:

To assure initiation of completion of the Death Certificate when an individual expires in this facility.

Policy: Transfer of a Patient to Another Acute Care Facility
Revised Date: 03/18

Transfer to Another Acute Care Facility

5. A Hospital to Hospital Transfer Consent form is to be completed...prior to patient leaving the hospital...the physician...the patient or family member are to sign the consent form...

The consent form will include:
C. Consent to transfer or do not consent checked
D. Signature of the patient...or responsible party
E. Witness signature
I. Transferring physician signature/date...
J. Destination hospital acceptance and room number
K. Accepted by, date, and time
L Accepting physician, date and time

1. MR # 6 was admitted to the facility on 11/1/18 with the diagnosis of Recent falls and Dementia. Patient expired on 11/16/18 at 11:20 AM.

Review of the form Record of Death for MR # 6 revealed the following items/ questions were left blank; Date and Hour of Admission, Date and Hour of Death, Mortician Report including body released by, date, Mortuary and Mortuary Address

Review of the form Authorization for Release of Body revealed the section for the "In Compliance with the Alabama Anatomical Gift Act, the signature of the survivor date and time including witness was left blank.

An interview was conducted on 6/27/19 at 11:00 AM with Employee Identifier (EI) # 1, Director of Patient Care Services who confirmed the staff failed to follow facility's policy and procedure on completion of medical record and it's forms.



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2. MR # 8 was admitted to the ED on 4/10/19 at 9:28 AM and transferred to another facility on 4/10/19 at 1:57 PM.

Review of the transfer form revealed the following items were blank:
Section I:
"I consent to transfer
I do not consent to transfer
Signature of patient or responsible party
Witness
Patient unable to sign due to
Date & Time"
Transferring physician signature...there was no date the physician signed the form.

Section III - Hospital Acceptance
"Acceptance from"....there was no date and time.
"Accepting Physician"...there was no date and time.

An interview conducted on 6/27/19 at 10:30 AM with EI # 1 confirmed the above findings.

3. MR # 11 was admitted to the ED on 4/20/19 at 3:59 PM and transferred to another facility on 4/20/19 at 4:45 PM.

Review of the transfer form revealed there was no date the transferring physician signed the form and no documentation of "acceptance from..by...date and time."

An interview conducted on 6/27/19 at 10:35 AM with EI # 1 confirmed the above findings.

4. MR # 13 was admitted to the ED on 4/23/19 at 10:13 AM and transferred to another facility on 4/24/19 at 2:19 AM.

Review of the transfer form revealed no documentation of "acceptance from" date & time and "accepting physician" date and time.

An interview conducted on 6/27/19 at 10:38 AM with EI # 1 confirmed the above findings.

5. MR # 16 was admitted to the ED on 5/3/19 at 9:33 AM and transferred to another facility on 5/3/19 at 4:05 PM.

Review of the transfer form revealed there was no date the transferring physician signed the form and no documentation of "acceptance from..by...date and time."

An interview conducted on 6/27/19 at 10:40 AM with EI # 1 confirmed the above findings.

6. MR # 20 was admitted to the ED on 5/10/19 at 7:30 PM and transferred to another facility on 5/11/19 at 1:19 AM.

Review of the transfer form revealed there was no date the transferring physician signed the form.

An interview conducted on 6/27/19 at 10:45 AM with EI # 1 confirmed the above findings.

7. MR # 26 was admitted to the ED on 6/2/19 at 3:45 PM and transferred to another facility on 6/2/19 at 5:50 PM.

Review of the transfer form revealed there was no date the transferring physician signed the form and no documentation of who obtained the acceptance of the receiving facility.

An interview conducted on 6/27/19 at 10:50 AM with EI # 1 confirmed the above findings.

8. MR # 27 was admitted to the ED on 6/11/19 at 4:23 PM and transferred to another facility on 6/11/19 at 5:30 PM.

Review of the transfer form revealed there was no documentation of who obtained acceptance from the receiving facility and no date and time. Additionally, there was no documentation of the date and time of the accepting physician and no documentation of who gave report to the receiving facility.

An interview conducted on 6/27/19 at 10:48 AM with EI # 1 confirmed the above findings.