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Based on observation, staff interview, documentation review, and policy and procedure review, the governing body failed to ensure the hospital environment is maintained and safe for patients; and failed to ensure patient care supplies and/or equipment is stored in manner to ensure safety from theft, damage and/or contamination for three (3) of three (3) days of survey.

Findings Include:

Cross Refer to A-0700 for the hospital's failure to ensure the hospital environment was maintained and safe for patients.

Cross Refer to A-0724 for the hospital's failure to ensure patient care supplies and/or equipment was stored in a manner to ensure safety from theft, damage and/or contamination.

Review of the facility's "Amended and Restated Bylaws of the ... Governing Body" (dated 04/24/04) revealed: "Article I ...Article IV. Directors ...General Powers. The board of directors shall be the governing body of the corporation. The business of the corporation shall be managed by the board of directors ...Rights, Powers and Responsibilities. In general, the board of directors may enjoy and exercise all of the rights, powers and privileges and shall perform and discharge all the responsibilities and obligation and shall assume, as applicable, all of the liabilities ...".

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure physician's orders were dated and/or timed for two (2) of 15 patients reviewed, Patient #3 and #13.

Findings Include:

Review of the medical record for Patient #3 revealed the Medication Reconciliation Report dated 12/07/16, Admission Orders dated 12/07/16, and the Physician's Orders dated 12/09/17 contained no documented evidence of the date or time of the physician's signature.

Review of the medical record for Patient #13 revealed the ChartLink Physician Entered Orders dated 02/16/16 and 02/17/16 contained no documented evidence of the date or time of the physician's signature.

During an interview on 02/23/17 at 10:00 a.m. the Medical Records Director confirmed the physician's signature was not dated or timed on the physician's orders for Patient #3 and Patient #13.

Review of the facilities "Medical Staff Rule and Regulations - Medical Records" revealed: " ...All clinical entries in the patient's medical record shall be dated and authenticated... The Practitioner's orders must be written clearly, legibly and complete."

Review of the facility's "Health Information Management Policy and Procedure Manual" (approved 11/29/2016) revealed: " ... All entries must be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) responsible for ordering, providing, or evaluating the service furnished. All orders/entries must be dated, timed and authenticated promptly by the prescribing physician or another physician responsible for the care of the patient, even if the order did not originate with him or her."

No further facility documentation was submitted for review during Exit Conference on 02/23/17 at 2:10 p.m.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure the hospital environment was maintained and safe for patients during three (3) of three (3) days of survey.

Findings Include:

Observation of the Dirty Surgical Instrument Room on 02/21/17 at 1:25 p.m. revealed the entrance door, accessible from the visitor hallway, was unlocked and had no signage. During the observation, Central Sterile Technician #1 stated that the Dirty Surgical Instrument door was left open all the time for Emergency Room (ER) staff to enter to add dirty instruments to the room.

Observation of the Sterile Instrument Processing Room on 02/21/17 at 1:30 p.m. revealed that the entrance door, accessible from the visitor hallway, was unlocked and had no signage. During the observation Central Sterile Technician #1 stated that the Sterile Instrument Processing door was locked if staff members are not present. Observation also revealed that Central Sterile Supplies were being stored in a room adjacent to the Sterile Instrument Processing Room. The Central Sterile Supply Room did not have a door.

Observation of the Preoperative/Holding Room in the surgical suite on 02/21/17 from 3:15 p.m. to 3:30 p.m. revealed that Preop Bay #1 had a torn curtain and broken floor tile on either side of both entrance doors. No functioning call lights were noted in any of the three (3) patient bays. These observations were confirmed by Registered Nurse (RN) #1.

Observation of the Dirty Surgical Instrument Room on 02/22/17 at 9:30 a.m. revealed the entrance door, accessible from the visitor hallway, was again unlocked and continued to have no signage.

Observation of the Surgical Suite entrance doors on 02/22/17 at 9:32 a.m. revealed a lock was located at the top of the door. No other security mechanism was observed on the door. The entrance doors were unlocked and were accessible from the visitor hallway. A sign on the doors stated "Authorized Personnel Only" and "All visitors must report to Registration". No employees were observed in the surgical suite at the time of this observation.

During an interview on 02/22/17 at 9:58 a.m. RN #2 confirmed that the dirty instrument room door could be opened from the visitor hallway and did not have signage on the door; the door is left open all day, every day, for ER staff to bring in instruments used after hours. RN #2 also confirmed that the double doors to the Surgical Suite entrance had no security measure except the lock at the top of the door and that the entrance double doors are locked if no staff member is present in surgery.

Observation of the Dirty Surgical Instrument Room on 02/23/17 at 9:20 a.m. revealed the entrance door, accessible from the visitor hallway, was again unlocked and continued to have no signage.



Review of the facility's "Surgical Department Access" policy (reviewed 11/2016) revealed: "Policy: Surgical department access will be limited to OR (Operating Room) staff, ...employees and/or vendors with a designated job duty to be performed in that department ... Procedure: During normal business hours the surgical nursing team will monitor who accesses the surgical department and redirect them as needed ...After normal business hours the OR department will be locked. Limited access for emergency medication/supplies can be accessed by a Registered Nurse or pharmacy personnel. Environmental services will have access afterhours to perform department cleaning. For after hour access keys to the OR will be kept at the switchboard and will be signed in and out as needed."


Review of the facility's "OR Nurse Call System" policy (reviewed 11/2016) revealed: "Policy: OR call system in place to alert staff of immediate needs of patients and/or other staff members by having a call device readily accessible for the OR rooms and PACU. Procedure: There is a master station located behind the central OR nurses station that will alert the staff of the location of the call. The staff will be oriented on the use of the call system. The staff will be responsible on educating patients on the location and use of the call system. Staff member at the nurse's desk receiving the alert will respond to present call and reset the system to allow for future calls as needed."


Review of the facility's "Facility Upkeep" policy (reviewed 11/2016) revealed: "Director of facility will round daily and note any damages. Director will assign tasks to Maintenance agents to replace or repair. Director will contact and contract any outside company if repair cannot be handled in house. Department Directors will fill out a Work Request for any repairs that need to be completed and where. Facility Director will ensure repairs are complete and in proper safety and working order."


On 02/23/17 at 2:10 p.m. these findings were discussed during Exit Conference. No further facility documentation was submitted for review.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure the hospital environment was maintained and safe for patients during three (3) of three (3) days of survey.

Findings Include:

Cross Refer to A-0700 for the facility's failure to ensure the hospital environment was maintained and safe for patients.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure patient care supplies and/or equipment was stored in manner to ensure safety from theft, damage and/or contamination during three (3) of three (3) days of survey.

Findings Include:

Cross Refer to A-0700 for the facility's failure to ensure patient care supplies and/or equipment used for patient treatment in dirty surgical instrument room, sterile instrument processing room and the central sterile supply room was maintained and safe.

Based on observation, review of disinfectant test strip documentation log, review of test strip use directions, staff interview, job description review, and policy and procedure review, during three (3) of three (3) days of survey the facility:
1. failed to ensure the surgical staff performed the solution test strip and documented the results of the test strip each time the high-level disinfectant solution was used to clean flexible scopes; and
2. failed to maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Findings Include:

Observation of the surgical suite on 02/21/17 at 1:35 p.m., made with Central Sterile Technician #1, revealed the facility had one (1) endoscope processing machine. Central Sterile Technician #1 stated, "We use a high-level disinfectant to clean endoscopes and a log of the usage is kept. A test strip is used to check the solution each surgical day."

Review of the high-level disinfectant test strip log documentation from July 2016 to February 2016 revealed the surgery staff used the solution test strips to check the results of the high-level disinfectant prior to usage only at the beginning of each day. On 02/22/17 at 10:07 a.m. and again at 10:20 a.m. RN #2 confirmed that the surgery staff check the solution at the beginning of the day, but not prior to each usage.

Observation of the solution test strip container on 02/22/17 at 10:40 a.m. revealed "Expiration date 07/28/16". There was no documented date the container was opened or by whom. During the observation RN #2 confirmed the test strip container expiration date was 07/28/16 and the test strip container being observed was the container used by the surgery staff to check the high-level disinfectant solution result prior to cleaning endoscopes on 02/21/17.

During a telephone interview on 02/22/17 at 10:45 a.m. Central Sterile Technician #1 confirmed she was not sure if the endoscope processing machine documentation contained the results of the solution test strip. She stated, "On the days procedures are scheduled I check the high-level disinfectant solution with a test strip prior to usage on that day." When asked if she checked the solution with a test strip prior to each use she stated, "No.". When asked if she used the current bottle of test strips with the expiration date of 07/28/16 to check the solution on 02/21/17 she stated, "Yes." She stated that she did not realize the test strips were expired and could not remember when solution test strips were last ordered.

During an interview on 02/22/17 at 4:20 p.m. the Administrator was unable to submit a copy of the Director of Nurses Job Description.

During an interview on 02/23/17 at 10:50 a.m. the Infection Control Nurse confirmed there was no written facility policy in place for tracking post-op infections prior to the one submitted and reviewed by the facility on 02/22/17 at 3:10 p.m.

During an interview on 02/23/17 at 12:50 a.m. the Purchasing Manager stated that purchasing staff round daily each morning to departments to pick up orders for maintenance needs. He stated, "The last order for high-level disinfectant solution test strips was 04/8/16 for two (2) bottles and both were received." When asked when the most recent order for high-level disinfectant test strips was placed he stated, "On 02/22/17 for two (2) bottles and both were received on 02/23/17."

Review of the manufacturers' high-level disinfectant solution label revealed: "Intended Use: High Level Disinfection ...Storage and Disposal ...Do not reuse beyond 14 days or sooner as indicated by the ...Solution Test Strips ...Directions For use ...Cleaning/Decontamination: ... Use ...Solution Test Strips to monitor ortho-phthalaldehyde concentration before each use to detect the MEC (Minimum Effective Concentration) ...Follow the directions for use provided with the ...Solution Test Strips ...".

Review of the manufacturers' solution test strip label revealed: "A. Intended Use: The ...Solution Test Strips are semi-quantitative chemical indicators for use in determining whether the concentration of ortho-phthalaldehyde ...is above or below the minimum effective concentration (MEC) established for ....Solution ...B. Explanation of the Test: ...Solution. It is recommended that ...Solution be tested before each usage with the ...Solution test strips in order to guard against dilution, which may lower the ortho-phthalaldehyde level of the solution ...C. Chemical Principle of the Test Procedure ...When the concentration of orhto-phthalaldehyde is sufficient, a color change from light-blue to purpose occurs on the reagent pad at the end of the strips. D. Reagents/Storage ...Precautions: Do not use any remaining strips 90 days after opening the bottle ...F. Directions for Use ...2. Always note the date the bottle was opened and the "do not use after" date in the space provided on the bottle ...9. Read the results of the color reaction present of the indicating pad at 90 seconds after the test strip is removed from the solution ...To indicate an effective concentration of the solution, the indicating pad will be completely purple. Any shade of purple is acceptable ...Record the result of the test is a suitable log book ...I. Test Results Interpretation: The solution must be discard if the Test Strip indicated fail ...".

Review of the facility's "Director of Materials Management Job Description" revealed: "Summary: To establish and coordinate departmental policies and procedures affecting facility resources. To plan, direct, organize and control all activities related to materials management with the health system ...".

Review of the facility's "Job Description of Infection Control Nurse" reviewed on 11/2016, revealed: " ...Functions and Responsibilities: 1. The staff nurse member of the Infection Control (IC) Committee will be considered in charge of IC within the nursing service department ...6. Will work with the IC Committee in helping to keep down infections with hospital personnel and to be aware of any areas that might be a source of infection to hospital patients and personnel."
Review of the facility's "Chief Executive Officer Job Description" reviewed of 11/2016, revealed: "Summary: Administers, directs and coordinates all activities of the organization to carry out its objective in the provision of health care ...Oversees operations, the application and implementation of established policies, liaison with governing authorities, the medical staff and departments ...".

Review of the facility's "Cleaning of Flexible Scopes" policy revealed: "Policy: To outline the requirements of cleaning of flexible endoscopes ...Procedure: ...Manual Disinfection ...b. Prepare disinfectant according to the disinfectant label. If the dissolution is reused, it should be tested regularly according to the manufacturer's instruction or the individual institution's protocol to ensure the minimum effective concentration of active ingredients ...6. Automated Disinfection: ...f. The high-level disinfectant will be tested prior to every scope washing. g. Prepare disinfectant according to the disinfectant label. If the disinfectant solution is re-used, it should be tested according to the Manufacturer's instructions or the individual institutions protocol to ensure the minimal effective concentration of active ingredients. h. Remove the strip from the bottle and replace cap tightly. i. Completely submerge the test strip into the high-level disinfectant for two (2) seconds then remove. j. Remove excess solution by shaking the strip. k. Hold strip horizontal. l. Be sure to wait 90 seconds for an accurate reading of the test strip. Pad will be completely purple to indicate effective solution. If any blue remains on the pad the solution is ineffective and must be discarded. Record and initial results on the log. m. Upon opening a new bottle of test strips, write on the label the date the strips were opened, and the date 90 days from then, which will be the expiration date ...Make sure the strips are not expired ...7. Storage of Endoscope: ...c. Place a tag on the processed scope that indicates the date of processing, by who, and if it passed the leak test."

Review of the facility's "Post-Operative Infection Identification" policy revealed: "Policy: It is the policy of the facility to maintain an effective tracking and reporting system of post-operative infections. Purpose: To provide methods to identify post-operative infections and implement corrective action. Responsibilities: Ona monthly bases, Infection Control nurse or his designee shall compile a list of all surgical procedures performed two months prior. For each operating provide, a list of only his patients will be forwarded for documentation to reflect presence or absence of a suspected or confirmed post-operative infection ...A report which accounts for a response for each surgery shall be made to the Infection Control Committee ...".

Review of the facility's "Supply Distribution-Department Stock Requisitions" policy (reviewed 11/2016) revealed: "Policy: Items that are not part of the PAR Level Replenishment System will be ordered on Department Stock Requisition forms. These orders will be filled and delivered daily Monday thru Friday ...".

On 02/23/17 at 2:10 p.m. these findings were discussed during Exit Conference. No further facility documentation was submitted for review.

Based on observation, test strip documentation log review, test strip directions for use review, staff interview, and policy and procedure review, the facility:
1. failed to ensure the surgical staff performed the solution test strip and documented the results of the test strip each time the high-level disinfectant solution was used to clean flexible scopes; and
2. failed to maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases on one (1) of three (3) days of survey.

Findings Include:

Cross Refer to A-0747 for the facility's failure to ensure the surgical staff performed the solution test strip and documented the results of the test strip each time the high-level disinfectant solution was used to clean flexible scopes; and failed to maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Based on observation, policy review, and staff interview, the facility failed to ensure Emergency Services integration included expired suture sets.

Findings Include:

Observation on 02/21/17 at 10:30 a.m. revealed three (3) boxes of sutures sets with expiration dates of 01/2017.

This finding was discussed with the Administrator on 02/23/17 at 11:00 a.m.

Page 1 of the facility's Supply/Stock Rotation Reference #5025 Policy contained the following requirements: "Dated items are checked on packages during the rotation procedure. Any supply/stock items discovered that have reached or are near expiration will be pulled and processed according to policy. Medical Supplies that are expired or within a month of reaching their expiration date are pulled from shelf and returned to the Materials management Department for proper disposal. Those items are disposed of in trash unless items are sharp or biohazard materials. Those items are disposed of in a biohazard container."

Based on record review, observation, patient interview, staff interview, job summary review, and policy review, the facility failed to ensure that an ongoing program of activities was provided by a qualified Activity Director for swing bed Patients #19, #20, #21, #22 and #23, five (5) of 10 patients reviewed,

Findings Include:

Record review for Patient #19, #20, #21, #22, and #23 revealed no documented evidence that a multi-faceted activities program was being provided for patients.

Interviews on 02/23/17 from 9:00 a.m. to 9:25 a.m. with Patients #19, #20, #21, #22, and #23 confirmed that they were not being offered any sort of activities by an Activities Director, other staff members, or volunteers.

On 02/23/17 at 11:00 a.m. the Administrator stated that the facility did not have a qualified Activity Director after the prior Activity Director resigned approximately four (4) months ago. There was no documented evidence of Activity Calendars being developed.

Review of the facility's (undated) "Patient Activities Policy... Swingbed Program" revealed: "... The activities director is responsible for resident activities... Meaningful activities appropraite to the needs and interest of patients will be provided in an effort to promote opportunities for engaging in normal pursuits, including religious activities if so desired..."

Review of the facilities (undated) "Activities Director Job Summary Swing Bed Program..." revealed: "Plans and implements activities program. Engages patients in meaningful activities, plans activities in relation to the resident's individual interest and needs. Maintains a written activities treatment plan for each patient, reviews this plan at least every other week and makes revisions if necessary... Requirements: Is a qualified Activity Director in the State of Mississippi..."

Neither the activities policy nor the Activities Job Summary included the requirement for an activity calendar.

Based on record review, staff interview, and policy review, the facility failed to ensure medically-related social services by a qualified Social Worker (SW) to attain or maintain the highest practicable physical, mental, and psychosocial well-being for five (5) of 10 patients reviewed, Patients #19, #20, #21, #22, and #23.

Findings Include:

Record review for Patients #19, #20, #21, #22, and #23 revealed the records contained no documentation by a qualified SW.

During an interview with the Administrator on 02/23/17 at 11:00 a.m. she revealed the facility did not have a qualified SW after the prior SW resigned approximately four (4) months ago.

Review of the facility's "Purpose of... Swing Bed Social Services" policy revealed: "...Social Services Documentation: The Social Worker is responsible for preparation and upkeep of the following:
Social Assessment/Treatment Plan: Information pertaining to the patient's social situation, including pertinent family and medical background. Should include information concerning patient's overall ability and functioning... should include documentation of any social or emotional needs and/or problems. ...
Social Service Progress Notes: ... The progress note should also include weekly communication with the patient and their families regarding their care, progress and discharge plans..."

Based on staff interview and policy review, the facility failed to ensure that residents were assisted in obtaining routine and 24-hour emergency dental care.

Findings Include:

An interview with the Administrator on 02/23/17 at 11:00 a.m. revealed there was no documented evidence of the facility providing patients: assistance in making appointments; arranging for transportation to and from the dentist's office; and promptly referring residents with lost or damaged dentures to a dentist.

Review of the facility's Swing Bed Policies revealed there was no requirement for providing dental services to their patients.