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Based on the review of the facility's Plan of Correction approved by the State Agency on 8/10/15,medical records, policies and procedures, and inservice documentation and observations, it was determined the facility failed to:

a.) Follow the Plan of Correction concerning mandatory education regarding the use of restraints and seclusion and non-violent crisis intervention. Refer to A 164 and A 175

b.) Perfrom audits on all patient records discharged with orders for restraint and seclusion. Refer to A 164

c.) Monitor a patient while placed in restraints per the facility policy. Refer to 175

d.) Document a thorough assessment of patients who presented to the Emergency Department. Refer to A 392

e.) Thoroughly document wound assessments. Refer to A 392

f.) Thoroughly document wound care provided. Refer to A 392

g.) Follow the physician's orders for wound care. Refer to A 392

h.) Ensure medications were administered to patients as ordered by the physician. Refer to A 392

i.) All PRN (as needed) medications administered included documentation of the location for IM (intramuscular) injections and the patient response to the medication. Refer to A 392

j.) Follow the Plan of Correction concerning inservices and chart audits which was approved by the State Agency on 8/10/15. Refer to A 392

k.) Ensure the staff's documentation was accurate and complete. Refer to A 449

l.) Ensure all multi-dose vials were properly dated and labeled Refer to A 505

m.) Ensure all pots and pans used for serving patients were stored clean and dry. Refer to A 724

n.) Ensure the dietary sanitizing solution contained the proper amount of parts per million chemical solution. Refer to A 724

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

Based on the review of the facility's Plan of Correction approved by the State Agency on 8/10/15, medical records, policies and procedures, inservice documentation and observations, it was determined the facility failed to:

a.) Follow the Plan of Correction concerning mandatory education regarding the use of restraints and seclusion and non-violent crisis intervention. Refer to A 164 and A 175

b.) Perform audits on all patient records discharged with orders for restraint and seclusion. Refer to A 164

c.) Monitor a patient while placed in restraints per the facility policy. Refer to 175

d.) Document a thorough assessment of patients who presented to the Emergency Department. Refer to A 392

e.) Thoroughly document wound assessments. Refer to A 392

f.) Thoroughly document wound care provided. Refer to A 392

g.) Follow the physician's orders for wound care. Refer to A 392

h.) All PRN (as needed) medications administered included documentation of the location for IM (intramuscular) injections and the patient response to the medication. Refer to A 392

i.) Ensure all PRN (as needed) medications administered included the location and responses. Refer to A 392

j.) Follow the Plan of Correction concerning inservices and chart audits, which was approved by the State Agency on 8/10/15. Refer to A 392

k.) Ensure the staff's documentation was accurate and complete. Refer to A 449

l.) Ensure all multi-dose vials were properly dated and labeled Refer to A 505

m.) Ensure all pots and pans used for serving patients were stored clean and dry. Refer to A 724

n.) Ensure the dietary sanitizing solution contained the proper amount of parts per million chemical solution. Refer to A 724

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

Findings include:

An interview was conducted with Employee Identifier (EI) # 1, Director of Nurses was conducted on 9/1/15 at 2:30 PM. The surveyor requested all the chart audits that were completed for the Plan of Correction and the response was, "No chart audits have been conducted".

An interview with EI # 1 was conducted on 9/2/15 at 2:00 PM. EI # 1 was asked if the mandatory educations had been conducted. The response was, "They have not been completed".

An interview was conducted on 9/3/15 at 10:00 AM with EI # 7, Chief Executive Officer. The surveyor asked who was responsible for assuring the approved Plan of Correction (POC) was fully implemented and followed? The response was, "EI # 1 and EI # 8, Registered Nurse over Quality Assurance and Risk Management.

The surveyor asked EI # 7 if he was aware the POC was not fully implemented and followed? The response was, "Not to the extent as I have seen since this survey began."

The surveyor ask if there was a reason why the audits that were to be completed for the restraints/seclusion, accurate orders, patient behaviors and wounds were not done? The response was, "I have no reason why it was not done."

Based on the review of the facility's Plan of Correction approved by the State Agency on 8/10/15 and inservice documentation, it was determined the facility failed to:

a.) Follow the Plan of Correction concerning mandatory education regarding the use of restraints and seclusion and non-violent crisis intervention. Refer to A 164 and A 175

b.) Perform audits on all patient records discharged with orders for restraint and seclusion. Refer to A 164

c.) Monitor a patient while placed in restraints per the facility policy. Refer to 175


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

Based on the review of the facility's Plan of Correction approved by the State Agency on 8/10/15 and inservice documentation, it was determined the facility failed to follow the Plan of Correction concerning mandatory education regarding the use of restraints and seclusion, non-violent crisis intervention, and documentation audits on all patient records discharged with orders for restraint and seclusion. This had the potential to affect all patients served by this facility.

Findings include:

Facility's Plan of Correction approved by the State Agency on 8/10/15:

482.13(e)(2) Patient Rights: Restraint or Seclusion (A 164)

"Mandatory education regarding this policy and use of restraints and seclusion will be given to all hospital RNs (Registered Nurses) and all Senior Care Unit (Geripsych) Unit staff members.

Activities that have already been accomplished: staff provided education on non-violent crisis intervention (CPI) (Crisis Prevention Institute) completed 4/24/15 & 8/1/15.

Documentation audits will be performed monthly on all patient records discharged with orders for restraints and seclusion."

Review of the documentation of inservices provided to the staff revealed 10 of 37 employees in the Senior Care Unit had received education of restraint and seclusion. Further review of the inservice documentation revealed no staff member for the Medical Surgical area of the hospital had received education on restraints and seclusion.

An interview was conducted with Employee Identifier (EI) # 1, Director of Nurses was conducted on 9/1/15 at 2:30 PM. The surveyor requested all the chart audits that were completed for the Plan of Correction and the response was, "No chart audits have been conducted".

An interview with EI # 1 was conducted on 9/2/15 at 2:00 PM. EI # 1 was asked if the mandatory education regarding the policy on restraints/seclusion and the use of restraints had been conducted. The response was, "Has not been completed".

Review of 4 of 4 personnel files of employees that were hired after 4/24/15 and before 8/1/15 were reviewed for CPI Training. None of the 4 employees had CPI Training.

An interview was conducted with EI # 1 on 9/3/15 at 9:50 AM. The surveyor asked EI # 1 stated she was going to attend the class to be certified as a CPI Trainer. The surveyor asked if the class was held on 8/1/15 and the response was, "No."

Refer to 175

Based on the review of medical records, the facility's Plan of Correction approved by the State Agency on 8/10/15 and the facility's policies and procedures and interview the hospital failed to:

a.) Monitor a patient while placed in restraints per the facility policy.

b.) Follow the Plan of Correction which was approved by the State Agency on 8/10/15.

This affected Medical Record (MR) # 11 (1 of 1 record with restraints ordered) and had the potential to affect all patients served.

Findings include:

Facility Policy: Safety Policy - Restraints
Revised: 8/30/00

Statement of Purpose:

"To provide guidelines for the therapeutic interventions necessary to protect a patient from physically injuring self or others and/or prevent the disruption of a therapeutic environment. Interventions will be limited to clinically justified situations employing the least-restrictive safe and effective restraint method. Protection and preservation of patient's rights, dignity, and well-being are ensured by maintaining a safe environment, assuring the patient's ability to care for him/herself not compromised, and to assure that the patient maintains a comfortable body temperature, modesty, and visibility to others..."

Procedure:

"5. The maximum length of time between observing the patient in restraints is every 2 hours. Due to the patients physical condition, emotional condition and absence of family members or significant others, the patient will be observed more often then every 2 hours as needed. Documentation will be made on the patients circulation, condition of the skin and limbs, attention to hydration, feeding, toilet, range of motion, and general condition as resting, still agitated, etc. the patient will be offered personal hygiene needs, nutritional needs as well as emotional and comfort needs. The restraint flow sheet will be used to document. Numbers 1, 2, and 3 must be filled out completely on the flow sheet."

Plan of Correction approved by the State Agency on 8/10/15:
482.13(e)(10) Patient Rights: Restraint or Seclusion

The WMC (Wiregrass Medical Center) staff will receive education upon hire and annually, including competency assessments on hire and annually.

Chart audits will be completed for accuracy of orders and assessment, trends identified will be reported...

The surveyor requested the medical records for all patients who were in restraints since the survey dated 7/10/15 from Employee Identifier (EI) # 1, Director of Nurses.

EI # 1 submitted MR # 11. MR # 11 was in ICU (Intensive Care Unit) on 7/31/15 on a BIPAP (Bilevel positive airway pressure). Review of the medical record revealed an order dated 7/31/15 at 7:10 AM for soft limb holders to the wrist.

Further review of the medical record revealed no documentation on the patient's circulation, condition of the skin and limbs, attention to hydration, feeding, toilet, range of motion, and general condition as resting, still agitated, etc after 5:00 PM on 7/31/15. Review of the Patient Progress Notes dated 8/1/15 at 6:22 AM revealed the restraints were removed.

The surveyor requested on 9/3/15 at 9:00 AM, the chart audit from EI # 1 for MR # 11. EI # 1 stated, "None had been completed".

An interview was conducted on 9/3/15 at 9:05 AM with EI # 1. EI # 1 verified there was no documentation on the patient's circulation, condition of the skin and limbs, attention to hydration, feeding, toilet, range of motion, and general condition as resting, still agitated, etc, every 2 hours as per the facility policy. EI # 1 stated the night nurse failed to document the the patient's circulation, condition of the skin and limbs, attention to hydration, feeding, toilet, range of motion, and general condition as resting, still agitated, etc.

Based on review of medical records and interviews, the hospital failed to assure staff:

a.) Documented a thorough assessment of patients who presented to the Emergency Department. Refer to A 392

b.) Thoroughly documented wound assessments. Refer to A 392

c.) Thoroughly documented wound care provided. Refer to A 392

d.) Followed the physician's orders for wound care. Refer to A 392

e.) Administered medications to patients as ordered by the physician. Refer to A 392

f.) All PRN (as needed) medications administered included documentation of the location for IM (intramuscular) injections and the patient response to the medication. Refer to A 392

g.) Followed the Plan of Correction approved by the State Agency on 8/10/15. Refer to A 392

Based on review of medical records, the Facility's Plan of Correction approved by the State Agency on 8/10/15 and interviews, the hospital failed to assure staff:

a.) Documented a thorough assessment of patients who presented to the Emergency Department.

b.) Thoroughly documented wound assessments

c.) Thoroughly documented wound care provided

d.) Followed the physician's orders for wound care.

e.) Administer medications to patients as ordered by the physician.

f.) All PRN (as needed) medications administered included documentation of the location for IM (intramuscular) injections and the patient response to the medication. Refer to A 392

g.) Followed the Plan of Correction concerning chart audits and inservices, which was approved by the State Agency on 8/10/15.

This had the potential to affect all patients served and did effect Medical Records (MR) #s 4, 9, 6, 5, 10, 12, and 7 (7 of 11 records reviewed). Findings include:

Facility's Plan of Correction approved by the State Agency on 8/10/15:
482.13(c)(2) Patients Rights: Care in Safe Setting

"All medications administered IM will be recorded, including location and the response of medication will be recorded in the medical record."

************

Addendum to the Plan of Correction dated 8/5/15:

482.13(c)(2) Patients Rights: Care in Safe Setting:

"All medications administered on an as needed basis will be documented in the medical record; to include medication type, administration site, and the patient's reason for the medication. The patient will be reassessed with documentation within one hour as to their response to the medication."

************

Facility's Plan of Correction approved by the State Agency 8/10/15:
482.23(b) Staffing and Delivery of Care

"...All RNs (Registered Nurse)/LPNS (Licensed Practical Nurses) will be educated on the importance of daily assessments of wounds, dressing change technique, and the documentation per policy.

Skin Assessments and wound care will be monitored by randomly by nursing services. Ten wounds per month will be monitored..".

Addedum # 1 dated 8/5/15
482.23(b) Staffing and Delivery of Care

"All wound care charts will be audited monthly for wound documentation to include measurements, condition of wound, and for appropriate physician orders."

1. MR # 4 presented to the Emergency Department (ED) on 8/24/15 at 9:10 PM with his/her mother with a complaint of possible sexual assault. MR was triaged at 9:10 PM and assessed by the ED physician at 9:18 PM. A review of the ED Physician Record documented the following:Chief complaint: " question as to sexual assault - was @ (at) father's house this weekend. " History of present illness: " Mom states father previously shook child when was an infant. " Onset: "This past weekend." Similar Symptoms Previously: "Yes"Genitals: No bleeding, no bruising, no abrasion
Skin: Normal
Diagnosis: Normal exam
Discharge: Home
Discharge instructions: Return if worsens has any problems follow up with primary medical doctor as needed. Destin or Zinc Oxide to bottom as needed.

MR # 4 was discharged from the ED at 9:44 PM.

The medical record contained no documentation of what the alleged sexual assault was, if the patient or patient's mother provided a description of the assault, if the authorities were notified of the alleged sexual assault or a reason for the mother to be instructed to use Destin or Zinc Oxide to MR # 4' s bottom as needed.

Written questions were submitted to hospital staff on 9/02/15. The hospital provided written responses and Employee Identifier (EI) # 1, Director of Nursing, confirmed the responses with the surveyor in an interview on 9/03/15 at 9:30 AM. The written responses stated the mother of MR # 4 told the ED doctor that the child had frequent irritation and was instructed to use Destin or Zinc Oxide as needed. Also, the mother did not "define" the sexual assault, only that she thought the father's girlfriend had possibly been the perpetrator and this was reported the following day by the ED manager to the Geneva County Department of Human Resources, child protective services.

EI # 1 confirmed the ED medical record did not thoroughly document information related to the purpose of the ED visit and staff follow up. In addition, EI # 1 confirmed the physician and nurse involved in this case were no longer employed by the hospital.

2. MR # 9 was admitted to the hospital on 8/27/15 with diagnosis to include Congestive Heart Failure, Pulmonary Edema, Hypertension and Anemia. Current laboratory values showed MR # 9's albumin was 2.1 and her protein level was 5.6.

On 8/28/15, there were physician orders for wound care as follows: apply maxsorb to right inner buttock wound, cover with a Telfa and change the dressing every 3 days and as needed.

On 8/29/15, nursing staff documented wound dressing was not present on the MR # 9's right buttock wound. Nursing staff documented maxsorb with bandaid was applied to the wound, not the ordered Telfa dressing.

On 8/30/15, nursing staff documented the soiled wound dressing was removed and the wound was left open to air. There was no documentation the physician was notified the wound was left open to air nor was there an order to leave the wound open to air.

On 8/30/15, nursing staff later documented the patient had a liquid bowel movement, linens were changed and the wound dressing was removed due to soiling. Staff documented the wound was left open to air and a moisture barrier was applied to the buttock area. There was no physician notification of the wound being left open to air nor a physician order to apply moisture barrier to the buttock area instead of the ordered wound dressing.

On 8/31/15, nursing staff documented patient had a loose bowel movement, patient was cleaned and moisture barrier applied to the buttock area.

On 9/02/15 nursing staff documented the patient had a pressure wound located to the right buttock with two open sores, one to the left and one to the right buttock area near mid-line. There was no documentation the physician was notified of the new open area.

On 9/02/15 nursing staff later documented a large bandaid over the maxsorb dressing was applied, not the ordered Telfa dressing.

There was no documentation of the wound measurements, description of the wound bed or documentation to support the wound care orders for MR # 9 were followed.

In an interview on 9/02/15 at 2:10 PM, with EI # 4, Infection Control/Employee Health nurse, the above information was confirmed.

3. MR # 6 was admitted to the Senior Care Unit (SCU) on 8/03/15 with a diagnosis to include Alzheimer's Disease, Mood disorder, Psychosis, Hypertension, Coronary Artery Disease, Atrial Fibrillation and Chronic Renal Failure.

A review of the medical record revealed hospital staff identified 11 different wounds from 8/03/15 to 8/18/15. A review of the physician orders revealed there were no wound care orders in place for MR # 6. A review of the care plans revealed there was no nursing skin care or nursing wound care plan in place for MR # 6.

The surveyor reviewed the nursing assessments and progress notes for MR # 6. There was only one wound measurement identified for only one wound, located on MR # 6's left upper arm/left outer forearm. None of the other identified wounds had been measured by nursing staff.

A review of the nursing notes revealed on 8/05/15, 8/09/15, 8/17/15, and 8/19/15 nursing staff provided wound care without a physician order. In addition, the wound care that was documented failed to document which wound was treated, the type of wound care provided, an assessment of the wound and how the patient tolerated the procedure.

In an interview on 9/03/15 at 10:05 AM, EI # 2, Interim Director of Nurses for SCU, confirmed the above findings.


17650


4. MR # 5 was admitted to the facility on 8/5/15 with diagnoses including Psychosis. This patient was admitted to the SCU.

Review of the physician's order dated 8/5/15 written at 6:30 PM revealed an order for the patient to receive Atorvastatin 10 mg (milligrams) once every night and Metformin 500 mg by mouth twice a day.

Review of the Medication Administration Record (MAR) dated 8/6/15 revealed the patient did not receive the Metformin in the AM.

Review of the MAR dated 8/17/15 revealed the patient received the Atorvastatin 10 mg two times that night.

An interview was conducted on 9/3/15 at 9:50 AM with EI # 2, Interim Director of Nurses in SCU. EI # 2 verified the above findings.

5. MR # 10 was admitted to the facility on 8/11/15 with diagnoses including Alzheimer's Disease, Dementia, and Psychosis.

Review of the Patient Progress Note dated 8/19/15 at 9:30 AM reveal, "patient very suspicious of staff, states he has been released, has gone to exit door and tries to leave...Patient refused (his/her) AM medication." The next entry in the Patient Progress Notes dated 8/19/15 was at 12:19 PM which included the patient consumed 100% of lunch.

Review of the physician's orders dated 8/19/15 at 1:50 PM revealed orders for Haldol 5 mg IM (intramuscular) NOW and Cogentin 1 mg IM NOW.

Further review of the Patient Progress Note dated 8/19/15 at 2:01 PM revealed the patient received an injection of the ordered Haldol and Cogentin. There was no documentation of the patient's behavior resulting in the need for the medication nor of a response to the medication.

Review of the Patient Progress Notes dated 8/23/15 at 1:43 PM revealed the patient received Haldol 5 mg and Ativan 2 mg IM for agitation. There was no documentation of the location of the IM injection.

Review of the physician's orders dated 8/31/15 at 8:55 AM revealed an order for Haldol 2.5 mg IM times 1 dose now. Review of the Patient Progress Notes dated 8/31/15 revealed the Haldol 2.5 mg IM was not given until 9:48 AM. There was no documentation of the location of the injection nor the patient's response.

Review of the physician's order dated 8/24/15 revealed orders for Neosporin Opthalmic Solution 1 drop to both eyes 3 times a day. Review of the MAR revealed the Neosporin Opthalmic Solution was only given 2 times a day on 8/25/15, 8/27/15, and 8/30/15 instead of the 3 times a day as ordered.

Review of the Physican's order dated 8/27/15 at 6:55 PM revealed orders for Calmoseptine to bilateral legs twice a day and PRN (as needed). Review of the MAR for 8/29/15, 8/30/15, 8/31/15 and 9/1/15 revealed no documentation the Calmoseptine was administered.

An interview was conducted with EI # 2 on 9/3/15 at 10:00 AM. EI # 2 verified the above findings.

6. MR # 12 was admitted to the facility on 8/27/15 with diagnoses including Psychosis. This patient was admitted to the SCU.

Review of the physician's orders dated 8/27/15 revealed the following medication orders:

Lisinopril 10 mg by mouth (po) every day
Mucinex DM (dextromethorphan) 30-600 mg 2 po 2 times a day
KCL (potassium chloride) 10 mEq (milliequivalent) po every day
Spiriva 18 mcg (micrograms) 1 inhalation every AM

Review of the MARs for 8/27/15 to 9/2/15 revealed no documentation the patient received the Lisinopril, KCL, or the Spiriva. Further review of the MARs for 8/27/15 to 9/2/15 revealed only 1 of the 2 Mucinex DM was being given to the patient 2 times a day.

An interview was conducted on 9/2/15 at 8:30 AM with EI # 2. EI # 2 verified the above findings.

7. MR # 7 was admitted to the facility on 8/17/15. The patient underwent a Right Colectomy on 8/17/15.

Review of the physician's order dated 8/17/15 at 8:48 AM revealed orders for a daily dressing change as follows: Cleanse with NS (normal saline) and apply Bactroban Ointment daily. Review of the medical record on 9/2/15 revealed no documentation of the wound care or a wound assessment on 8/19/15.

An interview with EI # 1 on 9/3/15 at 10:05 AM verified there was no documentation of wound care on 8/19/15.

An interview was conducted with EI # 1 on 9/1/15 at 2:30 PM. The surveyor requested all the chart audits that were completed for the Plan of Correction and the response was, "No chart audits have been conducted".

An interview with EI # 1 was conducted on 9/2/15 at 2:00 PM. EI # 1 was asked if the inservices for as needed medication documentation and wound care had been conducted. The response was, "They have not been conducted".

Based on review of medical records and the facility's policy and procedure and interview with the staff, it was determined the facility failed to ensure the staff's documentation was accurate and complete regarding treatment plans, discharge summary, progress notes and following the treatment plans.

This affected Medical Record (MR) #s 9, 5, and 10, which was 3 of the 4 records review of patient in the Senior Care Unit (Geripsych) and had the potential to affect all patients served by this facility.

Findings include:

Facility Policy: Interdisciplinary Assessment Overview
Unit: Senior Care Unit
No # documented
Date Issued: 9/06

1.0 Purpose: To establish the interdisciplinary assessment process.

2.0 Policy: Quality interdisciplinary treatment planning is based on assessments completed by team members. Each patient admitted to the Wiregrass Medical Center Senior Care Unit receives, but not limited to, the following:...

The Nursing Assessment is completed within 4 hours of admission...The Recreational Therapy Assessment and Occupational Therapy Assessment are completed within 72 hours...


1. MR # 9 was admitted to the facility on 8/27/15 with diagnoses including Psychosis. This patient was admitted to the Senior Care Unit (Geripsych).

Review of the medical record on 9/2/15 at 8:30 AM revealed no documentation of any Interdisciplinary Assessments or a Plan of Care.

An interview was conducted on 9/2/15 at 8:35 AM with Employee Identifier (EI) # 2, Interim Director of Nurses for the Senior Care unit. EI # 2 stated the Interdisciplinary Plan of Care should have begun the day the patient was admitted to the unit.

2. MR # 5 was admitted to the facility on 8/5/15 with diagnoses including Psychosis. This patient was admitted to the Senior Care Unit (Geripsych).

Review of the Interdisciplinary Treatment Plan Review dated 8/5/15 revealed a plan for exercise 5 times a week.

Review of the 13 Interdisciplinary Group/1:1 Therapy Flowsheets between 8/6/15 and 8/18/15 revealed exercises were performed on 8/8/15, 8/9/15, 8/11/15 and 8/16/15 which was 1 to 2 times a week.

Review of the Discharge Summary dated 8/19/15 revealed the patient was discharged home at 7:54 AM.

Review of the Patient Progress Notes completed by the nurse and dated 8/19/15 revealed the patient received Tylenol 325 mg (milligrams) at 3:22 PM, which was after the patient had been discharged from the hospital.

Review of the Senior Care Unit Discharge Planning Progress Notes dated 8/20/15 revealed the transport system would pick the patient up after 3:00 PM.

An interview was conducted with Employee Identifier (EI) # 2, Interim Director of Nurses SCU on 9/3/15 at 9:50 AM. EI # 2 stated the patient was discharged after 3:00 PM on 8/19/15 and could not explain the Discharge Summary completed on 8/19/15 at 7:54 AM and the Senior Care Unit Discharge Planning Progress Notes dated 8/20/15. EI # 2 also verified exercises were not offered 5 times a week.


3. MR # 10 was admitted to the facility on 8/11/15 with diagnoses including Alzheimer's Disease, Dementia, and Psychosis.

Review of the Interdisciplinary Treatment Plan Review dated 8/11/15 revealed a plan for exercise 5 times a week.

Review of the 21 Interdisciplinary Group/1:1 Therapy Flowsheets between 8/12/15 and 9/1/15 revealed exercises were performed on 8/13/15, 8/16/15, 8/22/15 and 8/28/15 which was 1 to 2 times a week instead of the 5 times a week.

An interview was conducted on 9/3/15 at 10:00 AM with EI # 2, who verified the above findings.

Based on observation, interview, facility policy and pharmacy memo and the facility's Plan of Correction approved by the State Agency on 8/10/15, the hospital failed to assure all multi-dose vials were properly dated and labeled in Operating Room (OR) number 1. This affected one of two operating rooms and had the potential to affect all patients served.Findings include:

Facility's Plan of Correction approved by the State Agency on 8/10/15:
482.42 Infection Control:

The nursing staff will be educated to label multi-dose products. Wiregrass Medical Center PolicySubject: Multi-dose vials, revised 3/2001"When a multi-dose vial is opened it is to be marked with the date and the nurse's initials."Memo from Pharmacy to all nursing staff dated 8/03/15 states in part: "Current policy states that all multi-dose vials must have a beyond use date of 28 days once the vial as (has) been opened. The pharmacy supplies beyond use stickers to all nursing areas."During a tour of the hospital OR # 1 on 9/02/15 at 10:25 AM, with Employee Identifier (EI) # 3, Manager of Surgery, the surveyor observed in the anesthesia cart the following multi-dose vials opened, but not dated or labeled:Lidocaine 2%Labetalol 100 milligramsNeostigmine 10 milligramsEI # 3 confirmed the multi-dose vials were not dated and labeled per the hospital's policy.

An interview with EI # 1, Director of Nurses was conducted on 9/2/15 at 2:00 PM. EI # 1 was asked if the nursing staff have been educated to label multi-dose products. The response was, "That has not been completed".

Based on policies, observation and interview the hospital failed to assure all pots and pans used for serving patients were stored clean and dry. In addition, the hospital also failed to assure the dietary sanitizing solution contained the proper amount of parts per million chemical solution. This had the potential to affect all patients served by the dietary department.Findings include:
Hospital Policy:
Pot and Pan Washing
Text: Pots and pans should be allowed to air dry. A clean large utility cart may be used for this due to lack of drain board space.

Hospital Policy:
Cleaning solutions (81A)
Purpose: To establish proper mixture for cleaning solutions.
Text: Solutions for cleaning buckets should be checked and changed every two hours.
During a tour of the dietary department on 9/01/15 at 10:50 AM, the surveyor observed three 1 quart pans stored wet and two 1 quart pans stored with a greasy film on the sides and bottom. During this same observation, the surveyor asked Employee Identifier (EI) # 5, Assistant Dietary Manager, to check the sanitization bucket stored under the food line area. EI # 5 checked the solution with a test strip and confirmed the result was between 0 and 150 parts per million (PPM). On 9/01/15 at 10:50 EI # 5, was asked what the PPM chemical solution should be and stated between 0 and 150. On 9/02/15 at 10:50 AM, EI # 6, Dietary Manager was interviewed and confirmed the PPM chemical solution for the red sanitization buckets should be between 200 and 400 PPM to be effective.