HospitalInspections.org

Based on review of medical records (MR), hospital policy and interviews with administrative staff, it was determined the facility failed to obtain a signed informed consent for patients admitted to hospital.

This affected 6 of 29 records reviewed including MR's # 4, # 5, # 8, # 10,# 12, and # 13 and had the potential to negatively affect all patients served by the hospital.

Findings include:

Policy Title: Informed Consent
Policy No.: AHW.100.0015
Revision Date: 05/11/16

Policy:

It is the policy of Crenshaw Community Hospital that all patient and outpatient medical records must contain a properly executed and completed written informed consent for all procedures and treatments specified by the facility's medical staff and state or federal laws/ regulations.

Crenshaw Community Hospital's consent process assures patients or their legal representatives are given the information and disclosures needed to make informed decision about whether to consent to surgery/ procedures/treatments.

1. MR # 4 was admitted to the hospital on 5/18/16 with primary diagnosis if Gastrostomy Tube Dislodgement.

Review of the MR on 5/23/16 revealed the Consent/ Authorization of Treatment, Conditions of Admission was not signed by patient or responsible party on admission. Employee Identifier (EI) # 12, Admission Staff documented " patient unable to sign". There was no documentation the facility contacted the patient's family or the responsible party.

An interview was conducted on 5/25/16 at 11:35 AM with EI # 3, Director of Nurses, who confirmed the above mentioned findings.

2. MR # 5 arrived in the Emergency Room (ER) on 2/26/16 with primary diagnosis of Chronic Obstructive Pulmonary Disease.

Review of the MR on 5/23/16 revealed the Consent/ Authorization of Treatment, Conditions of Admission was not signed by patient or responsible party on admission. EI # 12, documented " patient unable to sign". There was no documentation the facility requested the patient's spouse, who was at bedside, to sign the consent form.

An interview was conducted on 5/25/16 at 11: 37 AM with EI # 2, Assistant Director of Nursing (ADON), who confirmed the above mentioned findings.

3. MR # 8 was admitted to the hospital on 3/20/16 with the diagnoses including Severe Shortness of Breath, Chronic Obstructive Pulmonary Disease, History of Multiple Myocardial Infarction and Diabetes.

Review of the MR on 5/23/16 revealed the Consent/ Authorization of Treatment, Conditions of Admission was not signed by patient or responsible party on admission. EI # 12, documented " patient unable to sign". There was no documentation the facility contacted the patient's family or the responsible party.

An interview was conducted on 5/25/16 at 11:40 AM with EI # 2, who confirmed the above mentioned findings.

4. MR # 10 was admitted to the hospital on 5/2/16 with the diagnoses including Orthostatic Hypotension and Acute Kidney Injury.

Review of the MR on 5/23/16 revealed the Consent/ Authorization of Treatment, Conditions of Admission was not signed by patient or responsible party on admission. EI # 12, documented "patient unable to sign". There was no documentation the facility contacted patient's family or the responsible party.

An interview was conducted on 5/25/6 at 11:15 with EI # 2, who confirmed the above mentioned findings.

5. MR # 12 was admitted to the hospital on 5/19/15 with the diagnoses including Pneumonia, History of Old ischemic Encephalopathy and Percutaneous Endoscopic Gastrostomy (PEG).

Review of the MR on 5/23/16 revealed the Consent/ Authorization of Treatment, Conditions of Admission was not signed by patient or responsible party on admission. EI # 12, documented "patient unable to sign". There was no documentation the facility contacted patient's family or the responsible party.

An interview was conducted on 5/25/16 at 11:30 AM with EI # 2, who confirmed the above mentioned findings.

6. MR # 13 was admitted to the hospital on 1/7/16 with the diagnoses including Seizure and Ethyl Alcohol (ETOH) Abuse.

Review of the MR on 5/23/16 revealed the Consent/ Authorization of Treatment, Conditions of Admission was not signed by patient or responsible party on admission. EI # 12, documented "patient unable to sign". There was no documentation the facility contacted patient's family or the responsible party.

An interview was conducted on 5/25/16 at 11:45 AM with EI # 2, who confirmed the above mentioned findings.

Based on review of medical records (MR), Medical Staff Bylaws, policy and procedures and interviews, it was determined the facility failed to ensure the medical staff completed history and physicals within 24 hours of admissions.

This affected MR # 18, # 7, 2 of 18 patients admitted for inpatient services and had the potential to negatively affect all patients treated at the facility.

Findings Include:

Medical Staff Bylaws
Dated: 10/20/15

"III. Admission and Discharge

11. A complete history and physical examination shall be recorded within 24 hours of the patient's admission."

Facility Policy
Title: Medical Records
Review Date: 10/21/14

"Purpose: According to the medical staff bylaws ..., all History and Physicals must be dictated and on the charts within 24 hours of admission."

1. MR # 18 was admitted to the facility on 3/23/16 diagnosis of "found on floor and couldn't get up" and a history of "chronic kidney disease" and "leukocytosis".

Review of the MR revealed a History and Physical (H & P) signed by the admitting physician on 4/8/16, 16 days after admission.

In an interview conducted on 5/25/16 at 10:31 AM with Employee Identifier (EI) # 3, Director of Nursing confirmed the finding above.


34107


2. MR # 7 was admitted to the facility on 2/24/16 with the diagnosis including Right Lower Lobe Pneumonia.

Review of the MR revealed the H & P was signed by the physician on 3/2/16, 7 days after admission to the facility.

An interview was conducted on 5/25/16 at 10:58 AM with EI # 3, and confirmed the aforementioned finding.

Based on review of medical record (MR), policy and procedure, and interview, it was determined the nursing staff failed to ensure:

1. Wound assessments were conducted and documented per policy.

2. Wound care was provided according to the physician's orders.

This affected MR # 7, 1 of 1 admitted records reviewed with wounds and had the potential to negatively affect all patients served by the facility.

Findings include:

Facility Policy:
AHW.700.0010
Revision Date: 3/1/16
Wound Care, Measurements and Documentation

"Guidelines for wound measurement/ documentation...

Procedure:
1. Wounds should be measured on upon admission...
5. Length (L) is measured from patient's head to toe; Width (W) is measured from side to side...
6. Depth... deepest part of wound...

Dressing Changes Using Aseptic Technique

Procedure:
1. Upon admission to the hospital, all wounds will be assessed by a licensed nurse to determine the need for wound care...

4. If daily dressings changes are ordered the wound care will be as follows: ...
b. Cleanse wound bed and surrounding tissue with Dermal Wound Cleanser and ...
c. Apply treatment as directed by physician.
d. Apply hydrogel dressing.
e. Cover with dry dressing and secure with tape..."

1. MR # 7 was admitted to the facility on 2/24/16 with the diagnosis including Right Lower Lobe Pneumonia.

Review of the 2/24/16 Skilled Nurse (SN) Initial Assessment revealed the documentation of a Stage 1 wound to left heel and no measurements.

Review of 2/26/16 Physician's Order revealed, "Use Bactroban on heel wound daily."

Review of the 2/26/16 Nurse's Note revealed the wound to left heel as a Stage 3, Size- centimeters (cm) (L x W x D) 6 cm x 3 cm. SN cleansed with Normal Saline (NS), Bactroban applied and bulky gauze, wrapped with kling. There was no order for the wound care provided by the SN and the wound measurements did not include a depth to the wound.

Review of the Nurse's Notes dated for 2/27/16, 2/28/16, and 2/29/16 revealed the SN provided wound care as stated above.

An interview was conducted on 5/25/16 at 10:58 AM with Employee Identifier (EI) # 3, Director of Nursing, verified the SN failed to assess and document wound measurements on admission and obtain complete physician orders for wound care.

Based on United States Public Health Food Code 2013 regulations, observations and interview, it was determined the hospital failed to ensure food was stored in a safe and sanitary manner. This had the potential to negatively affect all patients.

Findings include:

United States Public Health Food Code 2013

3-501.17 Ready-to-Eat, Potentially Hazardous Food
(Time/Temperature Control for Safety Food),
Date Marking.
...commercially processed food open and hold cold
(B) Except as specified in ¶¶ (D) - (F) of this section, refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in
¶ (A) of this section and: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Pf and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety...
(C) A refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) ingredient or a portion of a refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest- repared or first prepared ingredient. Pf
(D) A date marking system that meets the criteria stated in ¶¶ (A) and (B) of this section may include:...
(2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under ¶ (A) of this section;
(3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under ¶ (B) of this section...

1. During a tour of the dietary department on 5/23/16 at 11:00 AM with the Dietary Manager, Employee Identifier (EI) # 9, the surveyor observed in the cooler:

A plastic gallon size container and labeled BBQ meat prepared 5/10/16 and discard 5/23/16 (a total of 13 days).

2 rectangular metal food pans covered with plastic wrap labeled jello prepared date on 5/21/16 and discard on 6/5/16 (a total of 15 days).

A gallon size container labeled tea prepared date on 5/20/16 and discard on 5/27/16.

EI # 9 verified at the time of the tour the containers were not labeled with the correct dates for disposal.

In an on interview conducted on 5/25/16 at 10:35 AM with EI # 3, Director of Nursing, confirmed the aforementioned findings.

2. A tour of the medical surgical unit was conducted on 5/24/16 at 7:45 AM. During the tour the patient nourishment refrigerator was noted to have the following outdated items:

5- 4 ounce (oz) containers of prune juice with the expiration date of 3/8/16.
8- 4 oz cartons of milk with the use by date of 5/15/16.
4- 4 oz cartons of milk with the use by date of 5/22/16.

In an on interview conducted on 5/25/16 at 10:35 AM with EI # 3, verified the aforementioned findings.

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 equipment, observations and interview it was determined the facility failed to maintain preventive maintenance (PM) on all equipment in the hospital. This had the potential to negatively affect all patients served.

Findings include:

1. A tour of the emergency department (ED) was conducted on 5/23/16 at 1:30 PM with Employee Identifier (EI) # 6, ED Director. The surveyor observed the portable ventilator with PM sticker dated 3/29/12.

The surveyor asked EI # 6 when the last PM was performed on the portable ventilator. EI # 6 provided a log with the date as 6/6/14 as the last PM performed.

In an interview conducted on 5/25/16 at 11:50 AM with EI # 6, verified the PM was not conducted annually.


28327


2. A tour of the Physical Therapy (PT) Department was conducted by the surveyor 5/24/16 at 9:45 AM with EI # 8, PT Office Manager. The surveyor observed the following equipment with no PM sticker, an expired PM sticker or and unreadable PM sticker:

Seca Scales: expired 11/14 PM sticker
Electrical (E) - Stem x (2): expired 11/14 PM sticker
Upper Extremity Bike: an unreadable PM sticker
Recumbent Bike: no PM sticker
Treatment Beds x 2: expired 11/14 PM sticker
Landice Treadmill: expired 11/14 PM sticker
True Treadmill: expired 11/14 PM sticker

An interview was conducted on 5/25/16 at 10:50 AM with EI # 3, Director of Nursing, who verified the aforementioned findings.

Based on observations, review of policies and procedures and interviews, it was determined the facility failed to ensure:

a) Staff performed hand hygiene and gloving as directed per the facility policy

b) Staff discarded single use items and items were not used for more than 1 patient in the Endoscopy Room.

This did affect an unsampled patient and had the potential to negatively affect all patients served by this facility.

Findings Include:

Facility Policy:
Policy Number: IC.100.0060
Title: Handwashing
Review Date: 5/16

"Policy: ...Handwashing is the single most important factor in reducing the risk of transmission of infectious agents and must be done to prevent the likelihood of hands serving as agents for the transfer of microorganisms. Hands are to be washed in the following instances:

...3. Before and after patient contact.
4. After contact with a source of microorganisms (...inanimate objects that are likely to be contaminated).
...7. Before and after tending to any personal need: (... or using the toilet)."

Facility Policy
Policy Number: 29
Title: Single Use Items
Review Date: 9/13

"It is the policy of Creshaw Community Hospital that the only single use items that may be sterilized and reused are Endoscopy Biopsy Forceps, snares, and Bicap hemostatic probes...

All other single use items and instruments will be disposed of ..."


1. During a tour of the Endoscopy Room on 5/23/16 at 1:05 PM with Employee Identifier (EI) # 2, Assistant Director of Nursing (ADON) and EI # 11, Scrub Technician, the surveyor observed a container covered with a towel sitting next to the Medivator (high level sterilizer). The surveyor asked EI # 11 what was in the container. EI # 11 lifted the towel and stated these are items that I place in the Medivator and reuse. The container had 4 clear plastic 4 x 4 disposable trays and 2 blue disposable trays.

The surveyor asked EI # 11, "How do you clean these trays (clear plastic and blue trays)? EI # 11 stated, "I put them in the Metivator". The surveyor then asks, "What would these trays be used for? EI # 11 stated, "To put sterile water in for when the physician needs to flush the scope during the procedure."

The facility did not follow there policy for disposable of single use items.

An interview was conducted with EI # 2 on 5/25/16 at 7:55 AM who confirmed the aforementioned findings.

2. During an observation of care in the Physical Therapy (PT) Department) on 5/24/16 at 10:00 AM the surveyor observed EI # 10, Licensed Physical Therapy Assistant (LPTA) providing therapeutic exercises to an unsampled patient.

Upon completion of the therapeutic exercises EI # 10 retrieved a disinfectant cloth and proceeded to disinfect the treatment table without applying gloves. EI # 10 then proceeded to the restroom without performing hand hygiene as directed per the facility policy.

An interview was conducted on 5/25/16 at 10:50 AM with EI # 3, Director of Nursing, who verified EI # 10 should have applied gloves when disinfecting and performed hand hygiene after patient care.


22965


3. An observation of a discharge patient room on the Medical/ Surgical Unit on 5/24/16 at 11:15 AM was performed by the surveyor to observe EI # 13, Housekeeping, terminally clean the room prior to a new patient arrival.

EI # 13 with gloves on, removed the bed linens from the hospital bed, EI # 13 realized the dirty linen cart was not at the door, he/ she left the room without removing the gloves and proceeded to get the dirty linen container from the Utility Room, placed dirty linens in the container. EI removed his/ her gloves and don new gloves without sanitizing/ washing hands. EI # 13 sprayed and wiped the bed, furniture and medical equipment in the room, removed her/ his gloves and don new gloves without sanitizing hands. With sanitized wipes and gloves on, EI # 3 wiped the garbage can and toilet fixtures, removed her/ his gloves and don new gloves without sanitizing hangs. After EI # 13 finished cleaning the room, she/ he removed the gloves, did not sanitized hands or wash her/ his hands and exited the room.

An interview was conducted on 5/24/16 at 12:00 PM with EI # 2, Director of Nurses, who concurred the staff should follow the Hand Hygiene and Infection Control practices and policy.

Based on review on medical records (MR), policy and procedures and interview, it was determined the facility failed to ensure staff provided and documented specific discharge instructions in 4 of 30 Emergency Department (ED) records reviewed. This affected ED records # 4, 13, 14, and 19 and had the potential to negatively affect all patients served by the ED.

Findings include:

Facility Policy
Discharge Instructions in the Emergency Department
#ER100.095
Review Date: 4/13/15

Policy:

All patients discharged from the ED will received condition- appropriate instructions for home care and appropriate referrals:...

Documentation shall include, but is not limited to:
Education and instructions for patient
Patient's response to instructions."

1. ED # 4 was admitted to the ED on 2/16/16 with the diagnosis to include Abscess. The patient was discharged from the ED after an incision and drainage (I&D) procedure.

There was no documentation of specific discharge (DC) instructions for how to care for the I&D site or signs and symptoms (S/S) of infection to monitor the surgical site for.

An interview was conducted on 5/25/16 at 11:50 AM with Employee Identifier (EI) # 6, ED Director, and verified the aforementioned findings.

2. ED # 13 was admitted to the ED on 3/19/16 with the diagnosis to include Difficult Urination.

Review of the 3/19/16 CT (Computed Tomography) report revealed a 2 millimeter (mm) stone in the upper right ureter.

Review of the 3/19/16 6:22 AM Nursing documentation revealed "DC home with Rx (prescription) x 5 and written dc instructions."

Review of the 3/19/16 Discharge Instructions at 6:27 AM revealed no documentation the patient was provided a urine calculi strainer or educated to monitor urine output for stone removal.

An interview was conducted on 5/25/16 at 11:50 AM with EI # 6, and verified the aforementioned findings. The surveyor was provided a charge form where the patient was charged for a calculi strainer.

3. ED # 14 was admitted to the ED on 3/26/16 with the diagnosis to include Cat Bite.

Review of the 3/26/16 DC Instructions revealed no education of S/S of infection to monitor the cat bite.

An interview was conducted on 5/25/16 at 11:50 AM with EI # 6, and verified the aforementioned findings.

4. ED # 19 was admitted to the ED on 5/7/16 with the diagnosis to include Lethargy.

Review of the 5/9/16 DC Instructions revealed, "Increase metoremen (Metformin) to 500 mg (milligrams) BID (twice a day). 200 cal (calorie) ADA (American Diabetic Association diet on GOOGLE."

In an interview conducted on 5/25/16 at 11:50 AM with EI # 3, Director of Nursing, verified the the aforementioned DC instructions were not complete.

Based on observation, review of facility policy and interviews with facility staff, it was determined the facility failed to maintain 36 vials of Dantrium (Dantrolene) in the Operating Room (OR) for the treatment of Malignant Hyperthermia.

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

Findings Include:

Facility Policy
Policy Number: 66
Title: Malignant Hyperthermia
Review Date: 9/13

"Standard: Incidents of malignant hyperthermia will be recognized and prevented and/or treated in the operating room.

Policy:

2. If malignant hyperthermia is suspected, the following steps shall be taken:

d. Circulating nurse ... obtain malignant hyperthermia cart/drug box.

e. Administer Dantrium ... Initial vials are available in the operating room. The pharmacy will assist in obtaining Dantrium as needed."

1. A tour of the OR was conducted on 5/23/16 at 1:05 PM by the surveyor and Employee Identifier (EI) # 2, Assistant Director of Nursing (ADON).

At 2:00 PM the surveyor asked EI # 2 where the Malignant Hyperthermia box was maintained. EI # 2 stated, "The Dantrolene is kept in the anesthesia cart".

A review of the anesthesia cart revealed 6 vials of Dantrolene. The surveyor asked EI # 2 if the facility had any other vials of Dantrolene and EI # 2 stated, "No there are none".

The facility failed to maintain 36 vials of Dantrolene for the treatment of Malignant Hyperthermia in the OR.

An interview was conducted on 5/25/16 at 10:50 AM with EI # 3, Director of Nursing, who verified the aforementioned findings.