HospitalInspections.org

Based on review of medical records (MR), personnel files and interview, it was determined the facility failed to ensure staff was competent to discontinue Peripherally Inserted Central Catheter's (PICC's) in the Emergency Department (ED). This affected Patient Identifier (PI) # 4 and # 10 and had the potential to negatively affect all patients who required removal of a PICC line in the ED.

Findings Include:

1. PI # 4 was admitted to the ED on 3/6/15 with a chief complaint of, "Remove Mid Line / PCC (PICC) Line".

Review of the MR revealed a physicians order dated 3/5/15, "Okay to remove mid line/PICC line after final dose antibiotics."

Review of Employee Identifier (EI) # 4, Registered Nurse (RN), documentation on 3/6/15 at 4:50 PM revealed, "PICC line removed from (L) left ... arm per MD (Medical Doctor) order..."

Review of EI # 4's, personnel file on 6/24/15 at 8:15 AM revealed there was no documentation of training or competency for PICC lines.

2. PI # 10 was admitted to the ED on 1/23/15 with a chief complaint of, "PICC line removal".

Review of the MR revealed a physicians order dated 1/23/15, "Remove PICC line."

Review of EI # 5, RN documentation on 1/23/15 at 6:10 PM documentation revealed, "...Pt (Patient) instructed to perform valsalva maneuver as PICC line removed by ... (EI # 5)."

Review of EI # 5's, personnel file on 6/23/15 at 3:00 PM revealed there was no documentation of training or competency for PICC lines.

An interview on 6/24/15 at 11:25 AM with EI # 1, Chief Nursing Officer, confirmed the above.

Based on observation and interview, it was determined the facility failed to ensure dietary products were stored in a clean environment in the Emergency Department (ED). This had the potential to negatively affect all patients who received care in this facility.

Findings Include

1. During a tour of the ED dirty utility room with Employee Identifier (EI) # 7, ED Nurse Manager, on 6/22/15 at 9:20 AM the surveyor observed canned soup and crackers in a cabinet, along with a coffee pot and microwave used to heat the soup sitting on the counter top. EI # 7, stated, "Those are for staff only."

During the tour at 10:00 AM, EI # 1, the Chief Nursing Officer, entered the ED and the surveyor walked into the dirty utility room with EI # 1 and ask him/her who the soup and crackers were used for. EI # 1, stated, "The patients, we know we have clean and dirty in the same room."

The surveyor submitted questions on 6/23/15 requesting a policy for clean verses dirty areas.

During an interview on 6/24/15 at 10:00 AM, EI # 1 stated that the facility did not have a policy and that they were "aware of issue".

Based on review of medical records (MR), policy and procedure and interview, it was determined the facility failed to ensure the dietitian performs nutritional assessments as directed per facility policy. This affected 1 of 10 (Patient Identifier [PI] # 20) inpatient records reviewed and had the potential to negatively affect all patients admitted to this facility.

Findings include:

Subject: Nutritional Assessment of Patients by the Clinical Dietitian

"Policy:

It is the policy ... that the Clinical Dietitian will complete a nutritional assessment within 48 hours of admission for patients initially screened as having moderate or high nutritional risk.

Purpose:

...To recommend appropriate nutrition intake, including caloric supplements, modified diets, enteral and parenteral nutrition."

Subject: Prioritization of Nutritional Consult

"Purpose:

To ensure the prompt nutritional intervention with an organized systematic approach to prioritize with criteria ... High Risk (24 hours), Moderate Risk (48 hours) ...

Policy:

The following risk criteria has been established to ensure that an effective nutritional intervention will occur.

High Risk (24 hours):

... Enteral (... PEG{percutaneous endoscopic gastrostomy})"

Subject: Enteral and Total Parenteral Nutritional

Purpose:

To monitor the appropriateness and administration of tube feeing formulas.

To monitor nutritional status of patients on tube feeding or total parenteral nutritional throughout their hospital course.

Procedure:

...The Clinical Dietitian is responsible for the evaluation of the appropriateness of the feeding modality ordered and the monitoring of the administration and patient's acceptance/tolerance of the feeding. This accomplished by:

Monitoring of oral intake (if patient is receiving and) and calculation of calories, protein and any other pertinent nutrient provided by nutrition support.

Assess appropriateness of current enteral/parenteral nutrition support and make recommendations for change as needed.

Completion of nutritional assessment and periodic reassessments ...

Charting pertinent nutrition information in patient's medical record ..."






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1. PI # 20 was admitted to the facility on 3/2/15 with diagnoses including Acute Diverticulitis, Left Lower Quadrant Periphilar Pneumonia and Malnutrition.

Review of the 3/2/15 Physician Orders revealed, "Start feedings at 50 milliliter (ml) / hour (hr). Start at 9:00 PM and DC (discontinue) at 0600 hrs (6:00 AM)."

Review of the 3/2/15 9:05 PM Progress note revealed skilled nurse (SN) documentation of "Tube feeding Vital AF (advanced formula) 1.2 Cal (calorie) started at 50 ml/ hr as ordered via pump."

Further review of the 3/3/15 at 12:07 AM SN note revealed documentation of, "Disconnected PEG tube feeding for labs in AM. Patient to remain nothing by mouth (NPO)."

Review of the 3/3/15 at 8:24 AM Nutritional Assessment revealed it was completed by Employee Identifier (EI) # 9, Dietary Manager.

An interview was conducted on 6/24/15 at 11:50 AM with EI # 10, Registered Dietitian (RD) and it was confirmed the patient's nutritional assessments were not being performed by the RD.

In an interview conducted on 6/24/15 at 12:40 PM with EI # 1, it was confirmed the physician failed to write complete orders for enteral feedings; the SN failed to contact the physician for the type of enteral feedings for the patient or follow physician orders, and the RD failed to perform a nutritional assessment.

Based on observations during facility tour with hospital staff and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on review of medical records (MR), policy and procedures, "Alabama Notifiable Diseases/Conditions" and interview, it was determined the facility failed to ensure staff reported 1 of 1 patients reviewed requiring notification to the local health authority within 5 days for a reportable disease. This affected Patient Identifier (PI) # 11 and had the potential to negatively affect for all patients at this facility.

Findings Include:

Facility Policy:
Title: Infection Control
Effective Date: October 2004

"Reportable Diseases

Purpose: To report diseases to the state as required by law.

Policy: Health care facilities are required by law to report certain disease. A list of these disease and the report forms from the health department are maintained and reporting is done as required."

Alabama Notifiable Diseases/Conditions
Date: 12/31/14

"Standard Notification Disease/Condition - Report by electronic means as specified by the Department, in writing, or by telephone or the County or State Health Department within 5 days of diagnosis, unless otherwise noted: ...Varicella."

1. PI # 11 was admitted to the Emergency Department on 1/21/15 with complaint of "Chicken Pox".

Review of the MR revealed the physician documented on 1/21/15, "Varicalla - mild ..."

There was no documentation the staff notified the County or State Health Department within 5 days as directed per the facility policy.

An interview was conducted on 6/24/15 at 11:40 AM with Employee Identifier # 1, Chief Nursing Officer, who confirmed the aforementioned findings.

Based on observations, review of policy and procedures and interview, it was determined the facility failed to ensure staff cleaned non-disposable equipment between patients. This affected Patient Identifier (PI) # 28 and had the potential to negatively affect all patients in this facility.

Findings include:

Subject: Daily Cleaning of Work Areas
Reviewed: 3/04

"Purpose:

To insure and protect patients against cross-contamination.

Policy:

Furniture and equipment in each unit, or bed area, will be cleaned off with hospital approved germicide.

....Units will be inspected to insure that it is clean before being used."

1. On 6/23/15 at 7:35 AM the surveyor observed Employee Identifier (EI) # 8, Registered Nurse (RN), perform medication preparation. EI # 8 proceeded to PI # 28's room with the Vital Sign machine, which also has a pulse oximetry (ox) attached to it. EI #8 obtained PI # 28's blood pressure (BP) and O2 sat (Oxygen saturation). EI # 8 administered PI # 28's medications and placed/returned the equipment (BP cuff, tubing and pulse ox) into the rolling cart without cleaning. EI # 8 then proceeded to Room 123, an unsampled patient, and proceeded to obtain his/her vital signs without cleaning the equipment between patients.

During an interview on 6/24/15 at 12:42 PM with EI # 1, Chief Nursing Officer, confirmed the above findings.

Based on review of medical records (MR) and interview with administrative staff, it was determined the facility failed to ensure the initial discharge planning evaluation tool was complete.

This affected Patient Identifier (PI) # 20, PI # 23, PI # 25, and PI # 30, 4 of 4 patient records who were discharged and could negatively affect all patients served by this facility.

Findings include:

Policy: Utilization Management

"Scope of Program: The Utilization Management program provides and coordinates care and resources for inpatients and outpatients. The program is designed to coordinate the patient's plan of care from the day of admission until post discharge follow up. Each patient admitted to the facility will have a licensed nurse assigned to over see their care. The Utilization nurse assigned to the patient will review the patient's record at the time of admission and on a daily basis. The Utilization nurse will discuss discharge plans with the patient and the physician..."


"Discharge Planning: The Utilization Team member assigned to the patient's case will visit the patient and discuss anticipated discharge plans within 24 hours of admit (Monday-Friday). During the weekend the discharge planning will be performed by the nursing staff for example: referrals to home health, hospice, and durable medical companies...".


Review of 4 discharged MR's revealed there was no initial evaluation for discharge planning completed on 4 of the 4 records. This included PI # 20, PI # 23, PI # 25, and PI # 30.

An interview conducted 6/24/15 at 9:45 AM with Employee Identifier # 3, Registered Nurse, Quality Assurance, Infection Control, Discharge Planning, and Utilization Review, confirmed the above documentation.

Based on review on medical records (MR), policy and procedures and interview, it was determined the facility failed to ensure staff:

a) Provided and documented specific discharge instructions in 2 of 2 Emergency Department (ED) records reviewed with a Peripherally Inserted Central Catheter (PICC) line discontinued. This affected Patient Identifier (PI) # 4 and # 10.

b) Documented specific discharge instructions in 1 of 1 (PI # 24) outpatient surgery record reviewed.

c) Provided accurate discharge medication lists.
This affected PI # 20, 1 of 10 inpatient records reviewed.

This had the potential to negatively affect all patients in the ED and outpatient surgery in this facility.

Findings include:

Subject: Discharge Instructions Sheet
Related to: Emergency Department
Reviewed: 3/08

"Purpose:

Establish guideline for completing the ED discharge sheet.

Policy:

When treatments are complete and the patient is ready for discharge, the instruction sheet will be complete as follows:

...Indicate with an X or check additional instruction sheets given.
...Check the two areas regarding care and instructions.
...Obtain patient or responsible other signature as evidence that understanding of the instructions has been obtained.
...Give the yellow copy to the patient and retain the white copy.
If patient leaves prior to signing discharge form then document this & (and) place discharge sheet with rest of the chart."

Subject - POC (Plan of Care) - Discharge Summary and Instructions
Reviewed: 5/11

"Purpose:

The purpose of the Discharge Summary and Instructions is to provide a means for documenting discharge instructions for the patient and for documenting a summary of the patient's hospital stay.

Policy:

The discharge instructions must be completed prior to discharge. After reviewing the discharge instructions with the patient and/or significant other, the nurse and the patient and/or significant other will sign the discharge instructions. A copy of the discharge instructions and drug information sheets will be given to the patient. Discharge documents are saved electronically."

1. PI # 10 was admitted to the ED on 1/23/15 with a chief complaint of, "PICC line removal".

Review of the MR revealed Employee Identifier (EI) # 5, Registered Nurse (RN), removed the PICC line as directed per the physicians order.

Review of the EI # 5's documentation on 1/23/15 at 6:10 PM revealed, "...Pt (Patient) instructed to perform valsalva maneuver as PICC line removed by ... (EI # 5) catheter intact on removal ... discharge instructions implemented by ... (EI # 5)."

There was no discharge instruction sheet or specific discharge instructions documented as directed per the facility policy.

2. PI # 4 was admitted to the ED on 3/6/15 with a chief complaint of, "Remove Mid Line / PCC (PICC) Line".

Review of the MR revealed a physicians order dated 3/5/15, "Okay to remove mid line/PICC line after final dose antibiotics."

Review of EI # 4, RN, documentation on 3/6/15 at 4:50 PM revealed, "PICC line removed from (L) left ... arm per MD (Medical Doctor) order..."

Further review of the MR revealed there were no specific discharge instructions or discharge instruction sheet documented as directed per the facility policy.

An interview on 6/24/15 at 11:25 AM with EI # 1, Chief Nursing Officer, confirmed the above.

3. PI # 24 was admitted for outpatient surgery on 6/22/15 for a Tonsillectomy and Adenoidectomy.

Review of the MR revealed Post Op (Operative) Instructions dated 6/22/15 at 12:44 PM signed by EI # 6, RN, as follows:
...Return to see: ... on: "Pt's (Patient's) mother to call office)
Medications:
Medication/Dose: Amoxicillin 500 mg (milligrams po (by mouth) twice a day.

Medication/Dose: Tylenol # 3 take 1-2 tabs (tablets po as needed every 4 hr (hours)
Special Medication Instructions: No crunchy foods x (times) 2 weeks. Use chloraseptic spray as needed.

There were no check marks or x's as directed per the facility policy for: "It is best to take your medication before the pain gets to bad ..., If your pain is NOT controlled by the medication, you should call your doctor. Call if your temperature is > (greater than) 100.6. Report any of the following to your doctor: redness, swelling ..."

An interview on 6/24/15 at 12:10 PM with EI # 1, Chief Nursing Officer, confirmed the above areas should have been marked.



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4. PI # 20 was admitted to the facility on 3/2/15 with diagnoses including Acute Diverticulitis, Left Lower Quadrant Periphilar Pneumonia and Malnutrition.

Review of the 3/12/15 Physician's Order Sheet revealed the following medications that were not listed on the nursing discharge instructions:
Albuterol 0.042 % nebulizer 4 times a day (QID).
Synthroid 0.075 milligram (mg) PO daily.
Synthroid 0.1 mg PO daily.
Protonix 40 mg PO daily.
Diflucan liquid 1 teaspoon po daily for 10 days.
Oxygen at 2 liters via nasal cannula.

The nursing discharge instructions 3/12/15 listed Synthroid 0.15 mg daily.

In an interview conducted on 6/24/15 at 12:40 PM with EI # 1, it was verified the discharge medications ordered by the physician and the nursing discharge medication list did not match.