HospitalInspections.org

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

1. Physician orders were written for foot soaks 2 times a day.

2. Physician orders were written for wound care.

3. Wound care was performed as ordered by the physician.

4. Nursing staff documented follow up assessments when a PRN (as needed) medication is given.

5. Nursing staff documented the required wound care and wound appearance per facility policy.

6. Nursing staff notified the physician with need for wound care orders.

This did affect 4 of 8 inpatient MRs reviewed including, Patient Identifier (PI) # 15, PI # 17, PI # 12, and PI # 16 and had the potential to affect all patients served by the facility for inpatient services.

Findings include:

Facility Policy: Wound Policy and Procedure
Date Created: 11/19/21

Wounds:
Required Documentation For All wounds:

Location: Be consistent in the description of the location...

Measurements: Measurements are to be obtained on admission and every 7 days after...

Appearance of Wound and Wound Bed: Red, granulation noted, white.

Exudate/Drainage and Amount: Document type pus, serosanguinous, scant.

Skin Surrounding Wound: Swollen, intact.

Odor: if odor is present or no odor...

Daily Wounds:

Wounds are to be charted daily using HCH (Hale County Hospital) wound assessment shift note.

Facility Policy: Pain Assessment, Reassessment and Management
Reference Number: 1156
Effective Date: 11/16/21

Policy:

Hale County Hospital shall respect and support the patient's right to optimal pain assessment and management. Pain shall be assessed in all patients in the organization. The organization shall also address the appropriateness and effectiveness of pain management.

Procedure:

It is the responsibility of all clinical staff to screen all patients expeditiously for the presence or absence of pain...

If the screening assessment reveals pain is present in the patient, it is the responsibility of clinical staff to conduct an indepth clinical assessment of pain and periodic reassessments of the patient for determination of pain and relief from pain, including the intensity and quality (i.e. character, frequency, location and duration of pain) and responses to treatment...

If the screening assessment identifies pain is present, the admitting nurse performing the initial pain assessment shall utilize the Initial Pain Assessment Form, completing this and placing this form in the patient's medical reword for use by all patient care providers...

The patient shall undergo reassessment of pain at least once per shift and after every pain control mechanism employed by patient care providers.

Any patient care provider, from any department, who has implemented a pain control mechanism shall reassess the patient within one-half (1/2) hour to determine amount of pain control or relief achieved.

Pain control mechanisms shall include, but not limited to:

Medications administered for the control or relief of pain...

...Medications administered for the control or relief of anxiety

Management of the patient's pain is an interdisciplinary process and shall be included in the interdisciplinary plan of patient care...

Ongoing Reassessment:

As part of the reassessment, the multidisciplinary team shall assess and document the pain in terms of its duration, characteristics and intensity as well as the time of the pain, the pain rating and any use of analgesics.

If the pain is treated by use of medication the nurse will reassess pain score 1 hour post administration of pain medication and document in nursing notes response to medication..;

This ongoing reassessment shall be performed at least every shift and more often if the patient's pain has not been controlled...

1. PI # 15 was admitted to the facility on 8/11/21 with an admitting diagnosis of Acute Osteomyelitis of Phalanx of Left toe and Type II Diabetes Mellitus Uncontrolled.

Review of the MR revealed an order dated 8/11/21 Mupirocin Topical Ointment 2% 1 application 2 times a day to distal Lt (Left) 1-2 toes with 4 by 4 folded dressing and tape. Starting 8/11/21 at 2100 (9:00 PM).

Review of the Medication Administration Record (MAR) dated 8/11/21 to 8/16/21 revealed the order for the medication Mupirocin Topical Ointment 2%. Further review revealed no order for the foot soaks to the left foot.

Review of the HCH (Hale County Hospital) Shift Assessment dated 8/11/21 at 10:45 PM revealed the nurse documented under integumentary skin flaking: Wound Lt great toe and second toe. Dressing: clean dry and intact. There was no documentation the dressing change had been performed.

Review of the nursing progress note dated 8/12/21 at 10:48 AM revealed the nurse documented "up on side of bed soaking foot..." There was no documentation of what the Lt foot was soaked in and further review of the MR revealed no order for foot soaks.

Review of the nursing progress note dated 8/12/21 at 5:51 PM revealed the nurse documented Lt foot soaked wound care done. There was no documentation as to how the dressing change was performed, who completed the dressing change and what solution was used to soak the foot.

Review of the HCH Shift Assessment dated 8/12/21 at 6:21 PM revealed the nurse documented under integumentary "wound L (Left) great toe and second toe. Dressing clean dry and intact." There was no documentation the dressing change had been performed.

Review of the HCH Shift Assessment dated 8/12/21 at 8:06 PM revealed the nurse documented under integumentary "wound L great toe and second toenails removed. Dressing on, soak TID (three times a day)." There was no documentation the dressing change had been performed nor was there documentation the foot had been soaked. Further review of the physician orders within the MR revealed no order for foot soaks TID.

Review of the Physician Progress notes within the MR revealed the patient's great toe nail and second toe nail had been removed prior to admission to the hospital per the physician in his/her office.

Review of the HCH Shift Assessment dated 8/13/21 at 8:25 AM revealed the nurse documented under integumentary "wound L foot great toe and second toe, Red, Dressing C/D/I (clean dry and intact)." There was no documentation the dressing change had been performed.

Review of the HCH Shift Assessment dated 8/13/21 at 9:00 PM revealed the nurse documented under integumentary wound: "Open wound to L great toe and second toe Dressed." There was no documentation of how the dressing had been changed.

Review of the HCH Shift Assessment dated 8/14/21 at 3:09 PM revealed the nurse documented under integumentary wound: "RT (Right) great toe and second toe. Dressing clean dry and intact." There was no documentation the dressing change had been performed and improper documentation of which foot was to have the dressing change.

Review of the HCH Shift Assessment dated 8/14/21 at 8:01 PM revealed the nurse documented under integumentary wound: "L foot second toe PT (patient) soaks foot and applies Mupiorcin to area with dressing." There was no documentation the patient was to change the dressing, no documentation the left great toe was dressed, and no documentation the left foot was to be soaked.

Review of the HCH Shift Assessment dated 8/14/21 at 8:01 PM revealed the nurse documented under integumentary wound: "...skin intact, skin warm and dry. Dressing: clean,dry and intact." Under additional notes the nurse documented patient sitting up in bed, denies any pain at the time dressing to left great and second toe intact, patient states has been soaked and dressed a few minutes ago... There was no documentation the foot was to be soaked, no documentation how the dressing change had been performed or who had performed the dressing change.

Review of the HCH Shift Assessment dated 8/15/21 at 1:20 PM revealed the nurse documented under integumentary wound: "RT foot, second toe. Dressing: clean dry and intact.: There was no documentation the dressing had been performed.

Review of the HCH Shift Assessment dated 8/16/21 at 11:37 AM revealed the nurse documented under integumentary wound: "R (right) foot second toe recent toenail removed for great and second toe. Dressing: clean dry and intact." There was no documentation the dressing change had been performed and inconsistent documentation of location of the wound.

An interview was conducted on 12/2/21 at 11:55 AM with EI (Employee Identifier) # 3 , Director of Patient Care Services # 2 who stated the nursing staff should have documented how the dressing change to the left foot was completed, the nursing staff should have obtained an order for the foot soaks and that some of the documentation was inconsistent by documenting right foot instead of the left foot.

2. PI # 17 was admitted to the facility on 7/15/21 with an admitting diagnosis of Fall, Altered Mental Status.

Review of the MAR dated 7/16/21 revealed the patient received Lorazepam (Ativan) IV (intravenous) 0.5 mg (Milligrams) every 4 hours PRN (as needed) agitation at 9:24 AM, 1:24 PM and 6:56 PM.

Morphine IV push every 4 hours PRN pain was given at 9:24 AM, 1:24 PM, and 6:56 PM and on 7/17/21 the Morphine was given at 12:46 AM.

Review of the HCH Shift assessments for 7/16/21 revealed the only documentation the Lorazepam and Morphine had been given was at 7:57 PM the nurse documented "treated with PRN Morphine and Ativan." Further review of the shift assessment revealed after the Morphine and Ativan were given there was no documentation of a follow up by the nurse to ensure the patient was pain and anxiety free.

Review of the nursing progress notes and the shift assessment notes for 7/16/21 and 7/17/21 revealed no documentation Lorazepam and Morphine had been given nor was there documentation of a nursing follow up after medications had been given to ensure the patient was pain and anxiety free.

An interview was conducted on 12/2/21 at 3:00 PM with EI #3 who stated there was no documentation in the nursing notes except the one entry on 7/16/21 of any Ativan or Morphine was given or why it was given only the MAR has them documented. EI # 3 also stated the nursing staff are not performing a follow up observation after administration of the medication which should be in one hour after the medication was administered.

3. PI # 12 was admitted to the facility on 11/23/21 Post Left Hip Replacement. Admitted to Swing Bed.

Review of the MAR 11/23/21 to 11/28/21 revealed Acetaminophen Oral 650 mg every 6 hours PRN was ordered for fever or pain. The medication was administered on the following dates and times:
11/23/21 at 9:04 PM
11/24/21 at 8:50 AM and 8: 48 PM
11/25/21 at 8:40 AM
11/26/21 at 8:17 AM
11/27/21 at 8:15 AM

Review of the nursing progress notes dated 11/23/21 from 6:57 PM to 10:13 PM revealed no documentation per the nursing staff of any PRN medication given and no complaints per PI # 12 for the need for a PRN medication.

Review of the nursing progress note dated 11/24/21 at 9:06 AM the nurse documented "given PRN for pain." The nurse failed to document what type of PRN medication was given. Further review of the nursing progress notes dated 11/24/21 revealed no nursing follow up documentation to ensure the PRN medication assisted MR # 12 with the relief of pain.

Review of the nursing progress notes dated 11/24/21 revealed no documentation of a PRN medication given. Acetaminophen was given at 8:48 PM per MAR.

Review of the nursing progress notes dated 11/25/21 revealed no documentation of a PRN medication given. Acetaminophen was given at 8:40 AM per MAR.

Review of the nursing progress notes dated 11/26/21 revealed no documentation of a PRN medication given. Acetaminophen was given at 8:17 AM per MAR.

Review of the nursing progress notes dated 11/27/21 revealed no documentation of a PRN medication given. Acetaminophen was given at 8:15 AM per MAR.

Review of the nursing progress note dated 11/28/21 at 11:52 AM revealed the nurse documented "given PRN." Further review of the progress note revealed no documentation per the nurse of what PRN medication was given, what the PRN medication was for, and no follow up nursing assessment was documented to state the PRN medication relieved the symptoms.

An interview was conducted on 12/1/21 at 3:00 PM with EI # 3 who confirmed the nurse failed to document what the PRN medication was and failed to document a follow up to ensure symptoms were relieved per facility policy.



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4. PI # 16 was admitted to the facility on 9/16/21 with an admitting diagnoses of Cellulitis of Left Lower Limb and Sepsis.

Review of the HCH 9/29/21 10:03 AM Nursing Note revealed the nurse documented, "Has a red area to his/her coccyx. Duoderm placed over area and he/she is a Q (every) 2 hour turn from side to side." There was no documentation the physician was contacted about the red area and an order received to place duoderm over the coccyx.

In an interview conducted 12/2/21 at 2:24 PM, EI # 3 confirmed there was no documentation the MD was notified, an order received for duoderm, and the hospital did not have standing orders for wound care by the nurses.

Based on review of the Employee Files, Job Descriptions and interviews with the staff it was determined the facility failed to ensure the licensed staff completed CPR (Cardiopulmonary Resuscitation) in a timely manner.

Findings include:

Registered Nurse (RN) Job Description
Last Revision Date: December 2021

This job description covers the most significant duties performed...

Summary:

The Registered Nurse is responsible for the delivery of quality patient care through the nursing process of assessment, diagnosing, planning, implementation and evaluation.

Primary Responsibilities:

...2. Initiates or assists in hospital codes and CPR as required...

Knowledge and Skill Requirements:

...3. Current CPR certification...

Licensed Practical Nurse (LPN)
Last Revision Date: December 2021

Summary:

The Licensed Practical Nurse assumes the responsibility for direct nursing care of assigned patients under the supervision of a Registered Nurse or physician in the patient care area.

Knowledge and Skill Requirements:

...3. Current CPR certification

1. Review of EI (Employee Identifier) # 6, Registered Nurse (RN), employee file revealed the last CPR certification was completed on 1/26/17 and expired on 1/26/19 which is 2 years and 11 months past due.

2. Review of EI # 5, Licensed Practical Nurse/Infection Preventionist, employee file revealed the last CPR certification was completed on 3/21/19 which expired 3/21/21.

3. Review of EI # 8, RN, employee file revealed the last CPR certification was completed on 2/21/19 which expired on 2/21/21.

4. Review of EI # 9, RN, employee file revealed the last CPR certification was completed on 2/21/19 and expired 2/21/21.

An interview was conducted on 12/3/21 at 9:30 AM with EI # 3, Director of Patient Care Services # 2, who stated the above CPR cards were expired.



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5. Review of EI # 12, Licensed Practical Nurse, employee file revealed no CPR certification in the file since date of hire 10/7/19.

An interview was conducted on 12/3/21 at 11:10 AM with EI # 18, Chief Financial Officer/Human Resources, who confirmed CPR certification was expired on EI # 12.

Based on facility policy and procedure, observations, and interview with staff, it was determined facility nursing staff failed to compare the name and number on the patient's wrist band with the blood bank label at the patient's bedside prior to administration of blood.

This affected 1 of 1 blood transfusions observed, including an unsampled patient, and had the potential to affect all patients admitted to the hospital who required a blood transfusion.

Findings include:

Facility Policy: Blood/Blood Components-Transfusion: Whole Blood and Packed Cells
Policy Number: 1040
Policy Review Date: 11/22/2021

Policy:

Hale County Hospital provides a safe and uniform method of administration of whole blood and packed cells.

Procedure:

Essential Steps:

...With another Registered Nurse, LPN (Licensed Practical Nurse) or physician, compare the name and number on the patient's wrist band with that on the Blood Bank label. Check the blood bag identification number and ABO (blood type) and Rh (Rhesus factor) compatibility. Also, compare the patient's Blood Bank identification number with the number on the blood bag...This should be done at the patient's bedside to prevent transfusion error.

1. An observation of blood administration was made on 12/1/21 at 12:17 PM for an unsampled patient. Employee Identifier (EI) # 10, Registered Nurse (RN), and EI # 9, RN compared the Blood Bank identification number and blood bag at the east wing nurses station. EI # 10 then proceeded alone to the patient's room where the administration of blood was begun.

The facility nurses failed to compare the Blood Bank identification number, blood bag, and patient's blood bank wrist band together at the patient's bedside per policy.

An interview was conducted on 12/3/21 at 11:15 AM with EI # 2, Director of Patient Care Services # 1, who was notified of the above observations, and confirmed the blood should have been checked off at the patient's bedside, and the Blood Bank Number verified at the bedside.

Based on review of the medical records (MR), physician orders and interviews with the staff it was determined the facility failed to ensure all physician orders were written for treatments provided and were signed, dated and placed in the MR.

This did affect Patient Identifier (PI) # 15, 1 of 2 MRs review with wounds and had the potential to affect all patient's with wounds served by the facility.

Findings include:

1. PI # 15 was admitted to the facility on 8/11/21 with an admitting diagnosis of Acute Osteomyelitis of Phalanx of Left toe and Type II Diabetes Mellitus Uncontrolled.

Review of the MR revealed a physician order dated 8/11/21 Mupirocin Topical Ointment 2%
1 application 2 times a day to distal Lt (Left) 1-2 toes with 4 by 4 folded dressing and tape. Starting 8/11/21 at 2100 (9:00 PM). Further review of the physician orders dated 8/11/21 revealed no order for the soaks to the left foot.

Review of the nursing progress note dated 8/12/21 at 10:48 AM revealed the nurse documented "up on side of bed soaking foot..." There was no documentation of what the left foot was soaked in and further review of the MR revealed no order for foot soaks.

Review of the nursing progress note dated 8/12/21 at 5:51 PM revealed the nurse documented L (Left) foot soaked wound care done. There was no documentation what solution was used to soak the foot.

Review of the HCH Shift Assessment dated 8/12/21 at 8:06 PM revealed the nurse documented under integumentary wound L (Left) great toe and second toenails removed. Dressing on, soak TID (three times a day). There was no documentation of what the left foot was soaked with and no order in the MR of a soak TID. Futher review revealed PI # 15 had his/her toe nails removed prior to admission to the hospital by his/her physician.

Review of the HCH Shift Assessment dated 8/14/21 at 8:01 PM revealed the nurse documented under integumentary wound: Left foot second toe PT (patient) soaks foot and applies Mupirocin to area with dressing. There was no documentation the patient was to change the dressing or soak his/her own foot, no documentation what the foot was to soaked with, and no physician order the left foot was to be soaked.

Review of the HCH Shift Assessment dated 8/14/21 at 8:01 PM revealed under additional notes the nurse documented patient sitting up in bed, dressing to left great and second toe intact, patient states has been soaked and dressed a few minutes ago... There was no documentation the foot was to be soaked and who completed the dressing change.

An interview was conducted on 12/2/21 at 11:55 AM with EI (Employee Identifier) # 3 , Director of Patient Care Services # 2 who stated the nursing staff should have obtained an order for the foot soaks.

Based on observation, facility policy and staff interview, it was determined the facility failed to ensure that controlled medications were stored in a double locked storage area at the Medical/Surgical (med/surg) floor nursing station.

This had the potential to negatively affect all patient served by the facility.

Findings include:

Facility Policy Number: 6206
Subject: Controlled Drug Management on Patient Care Units
Department: Emergency/med/surg
Reviewed/Revision Date: 3/1/21

Purpose: To ensure adequate control, dispensing and accountability of all controlled substances in conformity with state and federal regulations.

Policy:

When not in use, the controlled substances storage area on each patient care unit must be kept double-locked and secure at all times.

1. A tour of the facility med/surg nursing floor controlled substance storage was conducted on 11/30/21 at 11:45 AM. During the tour Employee Identifier (EI) # 12, Licensed Practical Nurse, lead the surveryor to were the controlled medications were kept on the floor.

EI # 12 lead the surveyor to a room across from the nursing station which was open to the outside and without securement of a door and/or lock.

EI # 12 used a key to open the cabinet door to the controlled medications. Inside the following medications were sitting on the shelf in the cabinet and secured only with the lock of the 1 cabinet:

Klonopin 0.5 milligrams (mg) oral (po) medication.
Ambien 10 mg po medication
Ativan 1 mg po medication
Valium 10 mg po medication
Librium 25 mg po medication
Norco 5/325 mg po medication
Norco 10/325 mg po medication
Phenobarbital 16.2 mg po medication
Restoril 15 mg po medication
Tylenol # 3 po medication
Xanax 0.5 mg po medication
Ultram 50 mg po medication
Percocet 5 mg po medication
Percocet 10 mg po medication
Morphine 100 mg/5 ml (milliters) liquid medication, which per EI # 12 belonged to a patient who had passed away on 11/27/21 and the facility was holding it.
Ativan 2 mg/ml liquid medication, which per EI # 12 belonged to a patient who had passed away on 11/27/21 and the facility was holding it. There was no reason stated or documented of the reason the medication was being held.

In an interview conducted on 11/30/21 at 11:53 AM, EI # 12 confirmed the above medications were controlled substance and secured behind only 1 lock.

Based on facility policies, tour of the dietary department, review of personnel files, and interview, it was determined Hale County Hospital failed to:

1. Have a full time employee serving as Dietary Director.

2. Provide training for the dietary aide/cook designated by administration on 11/1/21 to be in charge of the dietary department in the absence of the dietary manager.

3. Place an open date on opened foods still in original container.

4. Destroy dented/swollen cans of food.

5. Discard foods by discard date labeled on container.

Findings include:

Facility Policy: Guidelines For Dietary Services
Policy Number: None
Policy Date: Not documented

The Director of Dietary Services must be a full time employee ...to oversee the operation of the dietary services. This authority includes the daily management of the service, implementing training programs for dietary staffing and assuring that established polices and procedures are maintained that address the following:

1. Safety practices for food handling
2. Emergency food supplies
3. Orientation, work assignment, supervision of work and personnel performance.
4. Menu planning, purchasing of food and supplies, and retention of essential records.
5. Quality Assurance Program Implementation.
6. Guidelines for acceptable practices of food service personnel and guidelines for kitchen sanitation.

Facility Policy: Infection Prevention and Control, Nutritional Services
Policy Number: 6035
Policy Date: Not documented

Policy:

Nutritional Services staff shall follow all appropriate infection prevention and control measures for all food service.

Responsibilities:

Nutritional Services Director shall:

...Provide for the proper receiving and storage of all food supplies.

Infection Prevention and Control Practices:

...Foods stored in opened original containers must be covered and dated.

Food Preparation:

...Food from broken packages, swollen cans ... shall be destroyed.

Refrigeration:

...All foods that have been prepared for service...shall be covered, dated and discarded after three (3) days, if not used.

1. Review of the personnel file for Employee Identifier (EI) # 16, Dietary Director, Payroll/Status Change Form revealed EI # 16 was hired on 2/27/17 as PRN (as needed) status. There was no other payroll/Status Change Form within the file.

2. Review of the personnel file for EI # 17, Dietary Aide/Cook, revealed no documentation of training by the hospital to manage Dietary Services in the absence of the Dietary Manager.

3. A tour of the Dietary Department was conducted on 11/30 21 at 10:45 AM, the following observations were made:

a. Milk Cooler: an open 1/2 gallon carton of orange juice, open 32 ounce carton of liquid eggs, and an open gallon of whole milk. None had a label on them with an opened date.

b. Dry Pantry: (2) 92 ounce cans of Highland Instant Mashed Potatoes dented with top of cans bulging.

c. Walk in Cooler: A styrofoam cup of beef consomme with use by date of 11/24/21, an opened 32 ounce jar of both strawberry and grape preserves with no label noting the open or expiration date.

The above observations were confirmed with EI # 16 on 11/30/21 at the time of the dietary tour.

In an interview conducted on 12/3/21 at 9:52 AM with EI # 18, Chief Financial Officer/Human Resources, EI # 18 confirmed EI # 16 was not a full time employee, and that EI # 17 had not received any training to manage Dietary Services in the absence of the Dietary Manager.

Based on observations and interview with Employee Identifier (EI) # 4, Director of Plant Operations, it was determined the facility failed to ensure EI # 4 documented the ceiling leaks in the Rehabilitation area. This had the potential to negatively affect all patients who receive therapy in the Rehabilitation area

Findings include:

On observation was conducted on 11/30/21 at 10:40 AM in the Rehabilitation room where patients were working with the EI # 19, Physical Therapist (PT) and EI # 13, Physical Therapy Assistants (PTA). During the observations the surveyor noticed multiple large brown areas on the ceiling tiles throughout the room where the patients complete their therapy. The surveyor asked the PT if they had a leak in the roof and he/she replied yes they do.

On 12/3/21 at 9:30 AM an interview was conducted with EI # 4. During the interview EI # 4 was asked about the brown stained ceiling tiles in the rehabilitation area. EI # 4 responded by stating the roof is leaking and we are putting a whole new roof on the hospital. The surveyor asked EI # 4 if he/she considered this leak a safety issue and EI # 4 stated "I guess it could be." EI # 4 was then asked by the surveyor if he/she documented the findings. EI # 4 stated they can not document everything they do in a day. The surveyor asked if he/she had the documented safety rounds performed for 2021 for the surveyor to review. EI # 4 stated he/she had never heard of safety rounds?

An interview was conducted on 11/30/21 at 10:50 AM with EI # 4 who stated he/she will begin to document safety issues found like the ceiling tiles in the Rehabilitation area.

Based on observations and interviews it was determined the facility failed to ensure expired supplies were not available for patient use.

This had the potential to negatively affect all patient served by the facility.

Findings include:

1. A tour of the facility medical-surgical nursing floor was conducted on 11/30/21 at 9:35 AM. During the tour the following expired supplies were found and available for patient use:

Nursing Station Crash Cart:
Pediatric Colorimetric CO 2 (Carbon dioxide) Detector x (times) 2 with an expiration date of 1/28/21.
Adult Colorimetric CO 2 Detector x 1 with an expiration date of 11/10/21.
Intravenous (IV) set x 1 with an expiration date of 10/1/2020.
IV set x 2 with an expiration date of 2/1/21.
IV start kit x 2 with an expiration date of 10/31/21.
24 Gauge (G) 0.75 inch (") IV needle x 1 with an expiration date of 7/31/2020.
24 G 0.75" IV needle x 3 with an expiration date of 12/31/2020.
16 G 1.16" IV needle x 1 with an expiration date of 9/30/2020.
16 G 1.16" IV needle x 3 with an expiration date of 12/31/2020.
18 G 1.16" IV needle x 1 with an expiration date of 5/31/21.
18 G 1.16" IV needle x 2 with an expiration date of 10/31/21.
King Systems King LT-D (airway device) size 5 with an expiration date of 4/19.
Endotracheal tube and stylet set size 4.5 mm (millimeters) with an expiration date of 8/28/21.
Endotracheal tube and stylet set size 8.0 mm with an expiration date of 12/28/2020.
Endotracheal tube and stylet set size 9.0 mm with an expiration date of 10/28/2020.

An interview was conducted on 11/30/21 at 11:33 AM with Employee Identifier (EI) # 11, Registered Nurse (RN), who confirmed the above supplies were expired and available for patient use.

2. A tour of the facility Emergency Department (ED) was conducted on 11/30/21 at 1:30 PM. During the tour the following expired supplies were found and available for patient use:

ED exam room # 3:
Central Venous Tray x 2 with an expiration date of 10/1/21.
Isopropyl Rubbing Alcohol x 2 with an expiration date of 10/21.
Adult Colorimetric CO 2 Detector x 2 with an expiration date of 9/24/21.
24 G 0.75 " IV needle x 2 with an expiration date of 2/28/21.
24 G 0.75" IV needle x 14 with an expiration date of 10/31/21.
16 G 1.16" IV needle x 1 with an expiration date of 9/30/2020.

ED exam room # 3 crash cart:
IV start kits x 2 with an expiration date of 10/31/21
IV start kit x 1 with an expiration date of 7/31/21.
Trocar Catheter Kit x 1 with an expiration date of 7/19.

An interview was conducted on 11/30/21 at 2:25 PM with EI # 6, RN, who confirmed the above supplies were expired and available for patient use.

Based on review of the facility Infection Control (IC) Program, Quality Assessment and Performance Improvement (QAPI) Program and facility Antibiotic Stewardship Program (ASP) it was determined the facility failed to maintain an active hospital-wide programs for the surveillance, prevention, and control of HAIs (Healthcare Acquired Infections) and other infectious diseases and for the optimization of antibiotic use through stewardship, demonstrate adherence to nationally recognized infection prevention and control guidelines, document reduction of the development and transmission of HAIs and antibiotic resistant organisms and monitor and document Infection prevention and control problems along with antibiotic use issues with collaboration with the facility QAPI program.

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

Findings include:

Refer to A 749, A 750, A 751, A 761, A 762, A 763, A 770, A 773 and A 777 for findings.

Based on observations, review of facility policy and procedure, Centers for Disease Control and Prevention (CDC) Frequently Asked Questions (FAQ's) regarding Safe Practices For Medical Injection, CDC Environmental Cleaning Procedures and interviews with the staff it was determined the facility failed to ensure:

1. Employees washed or sanitized hands per facility policy and procedure

2. The Physical Therapy Assistant (PTA) cleaned the exercise table and pillow after use prior to the application of clean linen.

3. The staff cleaned the rubber septum of the medication vial prior to piercing it as recommended per CDC

4. The staff cleaned all high-touch surface areas in the Emergency Department (ED) examination room(s).

This did affect 11 of 15 observations conducted at the facility and had the potential to affect all patients served by the facility.

Findings include:

CDC: Frequently Asked Questions (FAQs) regarding Safe Practices for Medical Injection
Reviewed Date: 6/20/19

"Medication Preparation Questions

1. How should I draw up medications?

Parenteral medications should be accessed in an aseptic manner (free from contamination caused by harmful bacteria, viruses, or other microorganisms). This includes using a new sterile syringe and sterile needle to draw up medications while preventing contact between the injection materials and the non-sterile environment. Proper hand hygiene should be performed before handling medications and the rubber septum should be disinfected with alcohol prior to piercing it."

Facility Policy Number: 4008
Subject: Hand Hygiene - CDC Guidelines
Department: Organizationwide
Reviewed/Revision Date: No date documented

Purpose: To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs and infections.

Policy:

...All staff shall use the hand hygiene techniques, as set forth in the following procedure...

...Before each patient encounter

...After coming in contact with patient's intact skin...

...After contact with medical equipment/supplies in patient areas

Always after removing gloves...

Procedure:

Using antimicrobial soap and water...

...Turn off faucets with used paper towel and discard.

CDC: 4. Environmental Cleaning Procedures
Reviewed Date: 3/27/2020

...Best Practices for Environmental Cleaning in Healthcare Facilities

4.1 General environmental cleaning techniques

...Common high-touch surfaces include:

bedrails...doorknobs...light switches..

4.2.1 Outpatient wards...General outpatient or ambulatory care wards include waiting areas, consultation areas, and minor procedural areas...

...Consultation/Examination...Clean...High-touch surfaces and floors...

1. An observation was conducted on 11/30/21 at 9:30 AM in patient room 137 with Employee Identifier (EI) # 11, Registered Nurse (RN), to observe a medication pass. After entering the patient room EI # 11 obtained a pill splitter and cleaned the pill splitter with an alcohol wipe. EI # 11 laid the alcohol wipe down on the rolling medication cart and split the medication needed. Once complete EI # 11 then wiped the pill splitter with the same used alcohol wipe which was lying on the rolling cart and failed to clean the pill splitter with a clean alcohol wipe.

An interview was conducted on 12/1/21 at 1:30 PM with EI # 3, Director of Patient Services # 2, who confirmed a new alcohol wipe should have been used to clean the pill splitter after use.

2. An observation was conducted on 11/30/21 at 10:40 AM in the Rehabilitation room to observe physical therapy assisting patients with exercises. During the observation a patient was using table # 1 to complete exercises. Once complete EI # 13, Physical Therapy Assistant (PTA) removed the sheet and pillow case from the table and put in soiled linen area. The Physical Therapist told EI # 13 where to obtain the cleaning supplies and EI # 13 replied ok. EI # 13 failed to obtain the clean supplies and clean the table and the pillow. EI # 13 applied a clean sheet to the table and a clean pillow case to the pillow and did not sanitize the area.

An interview was conducted on 12/1/21 at 11:30 AM with EI # 19, Physical Therapist, who confirmed therapy is to clean the tables and all equipment prior to placing clean sheets on the table and pillow

3. An observation was conducted on 12/1/21 at 11:40 AM with EI # 9, RN to observe a medication pass. EI # 9 went into the medication room to reconstitute Rocephine and add to the normal saline. EI # 9 once in the medication room donned clean gloves and failed to sanitize hands prior to donning the gloves. EI # 9 obtained a 10 cc (cubic centimeter) syringe and needle. EI # 9 then obtained a small bag of Normal Saline (NS) 100 cc's to add the medication to. EI # 9 inserted the needle into the bag of saline and did not sanitize the port on the bag of NS and with drew the fluid. EI # 9 then removed the cap from the medication bottle and inserted the needle into the rubber septum and failed to clean the septum prior to inserting the needle.

Once the medication was constituted, EI # 9 withdrew the medication from the bottle and failed to sanitize the septum of the bottle and inserted the needle into the port of the NS bag and failed to clean the port prior to inserting the needle.

EI # 9 then entered the patient room after sanitizing hands in the hallway and opening the door with bare hands. EI # 9 donned gloves in the patient room, cleaned the medication cart with germicidal wipes, removed gloves, did not sanitize hands and went to the bedside to observe the patient armband. After washing hands and donning gloves, EI # 9 obtained insulin from the medication cart, and an insulin syringe. EI # 9 drew up 2 units of insulin and failed to clean the septum of the insulin bottle prior to insertion of the needles. EI # 9 then removed gloves and did not wash hands or sanitize hands and connected the IV (intravenous) Rocephin to the primary IV bag and failed to wipe the port of the IV tubing prior to connection the medication bag.

An interview was conducted on 12/1/21 at 1:30 PM with EI # 3 who confirmed hands should be washed or sanitized when putting on clean gloves or when removing used gloves, the rubber septum should be cleaned with alcohol and the port on the IV bag.



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4. An observation was conducted on 11/30/21 at 2:36 PM with EI # 6, RN and EI # 7, Patient Care Technician, to observe administration of oral and Intramuscular (IM) injection medication.

EI # 6 entered the ED medication room and obtained Zofran 4 mg (milligram) pill, Morphine 4 mg vial, and a syringe and needle. EI # 6 removes the plastic top of the Morphine vial and inserts the syringe needle into the Morphine vial without disinfection of the rubber septum prior to piercing it.

EI # 6 entered the patient exam room, scanned the patient armband into the electronic medical record (EMR), donned gloves without performing hand hygiene and administered Zofran 4 mg orally.

EI # 6 request EI # 7 to enter the patient exam room to hold the patient's leg. EI # 7 enters the exam room, donned gloves without hand hygiene and after EI # 6 uncovered the patient's leg, EI # 7 held the patients left leg down onto the bed.

EI # 6 cleansed the patient's leg with alcohol then administered Morphine 4 mg IM to the patient's left leg. EI # 6 failed to change gloves prior to the administration of the IM injection and perform hand hygiene.

EI # 7 exited the exam room following the administration of the IM injection, without performing hand hygiene.

An interview was conducted on 12/2/21 at 10:34 AM with EI # 2, Director of Patient Care Services # 1, who verified the finding were not in complaince with facility policy.

5. An observation was conducted on 12/1/21 at 11:39 AM with EI # 8, RN, to observe an IM medication administration.

EI # 8 obtained Ketorolac medication vial, syringe, needles, and gloves in the ED medication room and places them on the EMR rolling cart.

EI # 8 entered the patient exam room, performs hand hygiene, donned gloves, draws the Ketorolac into the syringe, places syringe on top of the EMR rolling cart, scanned the Ketorolc vial then the patient armband into the EMR, then opened a new sterile needle, using same gloves and without hand hygiene, and changes the exiting needle on the syringe to the new sterile needle. EI # 8 then cleansed right buttock injection site and administered Ketorolac 60 mg IM.

An interview was conducted on 12/2/21 at 10:34 AM with EI # 2, who verified the finding were not in complaince with facility policy.

6. An observation was conducted on 12/1/21 at 11:55 PM with EI # 7, to observe the process for cleaning of the ED exam room following patient's discharge.

During the observation, EI # 7 failed to clean the left side handrail of the patient exam bed, the exam room doorknobs and light switches.

An interview was conducted on 12/2/21 at 10:34 AM with EI # 2, who verified the finding were not in complaince with facility policy.

7. An observation was conducted on 12/1/21 at 12:33 PM with EI # 9, RN, to observe an IV medication administration.

During the observation, EI # 9 performed hand hygiene twice using soap and water. After performing hand hygiene, EI # 9 used bare hand to turn the sink faucet off on both occasions.

An interview was conducted on 12/2/21 at 10:34 AM with EI # 2, who verified the finding were not in complaince with facility policy.

8. An observation was conducted on 12/1/21 at 12:50 PM with EI # 9, to observe the discontinuation of a nebulizer treatment.

During the observation, EI # 9 performed hand hygiene twice using soap and water. After performing hand hygiene, EI # 9 used bare hand to turn the sink faucet off on both occasions.

An interview was conducted on 12/2/21 at 10:34 AM with EI # 2, who verified the finding were not in complaince with facility policy.

9. An observation was conducted on 12/1/21 at 12:56 PM with EI # 10, RN, to observe an oral medication administration.

During the observation, EI # 10 performed hand hygiene twice using soap and water. After performing hand hygiene, EI # 9 used bare hand to turn the sink faucet off on both occasions.

An interview was conducted on 12/2/21 at 10:34 AM with EI # 2, who verified the finding were not in complaince with facility policy.



41624

10. On 11/30/21 at 9:38 AM the surveyor observed EI # 12 , Licensed Practical Nurse (LPN), administer oral medications to an unsampled patient. EI # 12 was already in the hallway at the time of observation, and entered the patient's room without performing hand hygiene. EI # 12 donned gloves without performing hand hygiene, and got a tissue to assist the patient.

EI # 12 did not follow facility policy to perform hand hygiene before each patient contact and after contact with medical equipment/supplies in patient areas.

An interview was conducted on 12/2/21 at 10:34 AM with EI # 2, Director of Patient Care Services # 1, who verified the finding were not in complaince with facility policy.

11. On 11/30/21 at 10:07 AM the surveyor observed EI # 12 administer a subcutaneous (SQ) medication. EI # 12 pulled the medication cart to the room and entered without performing hand hygiene. EI # 12 touched the bed controls to raise the head of the bed, then went to the computer keyboard to pull up the patient's information and scanned the patient's armband with the scanner. EI # 12 then donned gloves without performing hand hygiene, and touched the computer keyboard to open the medication drawer and remove a vial of heparin 5000 units that was ordered. EI # 12 removed the cap covering the septum of the vial, then changed gloves without performing hand hygiene, wiped the septum with an alcohol pad, drew up and administered the heparin sq to the patient's abdomen.

An interview was conducted on 12/2/21 at 10:34 AM with EI # 2, Director of Patient Care Services # 1, who verified the finding were not in complaince with facility policy.

Based on observations of care from 11/30/21 to 12/2/21, review of the facility Infection Control (IC) program, facility policy and the hospital 2021 hand hygiene and glove use surveillance data the hospital failed to evaluate and analyze the data, identify opportunities for improvement in staff hand hygiene adherence/performance and initiate improvement actions when benchmark(s)/goal(s) were not met.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

Facility Policy Number: 1201
Subject: Performance Improvement (PI) Plan
Department: Infection Control
Reviewed/Revision Date: No date documented

Purpose/Objective:
The Infection Prevention and Control Committee (IPCC) and Infection Preventionist(s) participate in a hospitalwide PI program designed to monitor, evaluate and improve the quality, appropriateness and outcomes of clinical services by:

...Identifying opportunities through continuous assessment of systems and processes of care through a collaborative, interdisciplinary focus.

Implementing solutions and actions which will bring about the desired change, to
Facilitate a positive patient outcome, while
Maintaining a safe environment for staff, patients and visitors.

Thresholds: Measurement of performance measures will be structured to focus on an improvement in patient care. Thresholds will represent either preestablished levels, that when reached trigger an intensive evaluation of the measure under review, or benchmarks that have been identified by facility experience, that require an indepth evaluation of the proposed performance aspect and related performance measures...

Methodology:

The Infection Preventionist(s)/Committee shall utilize the Plan, Do, Check, Act (PDCA) methodology to plan, design, measure, assess and improve functions and processes related to major patient care related activities.

Plan: ...The following data sources will be reviewed for use in the development of performance measures;
...Infection prevention and control surveillance and reporting

Benchmarks or thresholds that trigger intensive assessment and evaluation are established.

Do: Data is collected to determine:

...The level of performance and stability of existing processes
Priorities for possible improvement of existing processes

Check: The Infection Preventionist shall review and evaluate the data presented for analysis of outcome. Appropriate statistical methodology will be employed to analyze and display data. Evaluation shall focus on identifying opportunities to improve both the processes of patient care and actual identified problem areas that effectuate a negative outcome...Conclusions will be drawn regarding the evaluation of data presented with recommendations considered.

Act: Upon review of the data presentation, conclusion and recommendations, the Infection Preventionist/IPCC will take actions to resolve identified problems and will direct efforts to those areas which have the greatest potential for improving patient care...The Infection Preventionist/IPCC will perform follow-up monitoring to assure that actions taken are effective and that any progress achieved is sustained....

1. Review of the facility IC program was conducted on 12/2/21 at 3:14 PM with Employee Identifier (EI) # 5, Infection Preventionist. The surveyor reviewed the following hospital hand hygiene and glove use surveillance compliance documentation from January 2021 through October 2021: Benchmark 100%/Goal 100%

January-2021; 100 % compliance- 5 employees observed performing hand hygiene and glove use.
February-2021; 95% compliance- 5 employees observed performing hand hygiene and glove use.
March-2021; 96% compliance- 5 employees observed performing hand hygiene and glove use.
April-2021; 100 % compliance- 4 employees observed performing hand hygiene and glove use.
May-2021; 92% compliance- 4 employees observed performing hand hygiene and glove use.
June-2021; 100% compliance- 4 employees observed performing hand hygiene and glove use.
July-2021; 100 % compliance- 4 employees observed performing hand hygiene and glove use.
August-2021; 96% compliance- 5 employees observed performing hand hygiene and glove use.
September-2021; 100 % compliance- 4 employees observed performing hand hygiene and glove use.
October-2021, 100% compliance-4 employees observed performing hand hygiene and glove use.

Review of the hand hygiene surveillance compliance documentation from January 2021 through October 2021 revealed documentation 3 of the 4 months where hand hygiene compliance was below 100% involved the observation with 1 of the 5 departments (nursing, medical staff, radiology, laboratory, and environmental services) observed.

Further review of the facility IC program revealed no documentation the Infection Preventionist/IPCC evaluated and analyzed the data, identified opportunities for improvement in staff hand hygiene adherence/performance and initiated improvement actions when benchmark(s)/goal(s) were not met.

Review of the IC Committee meetings minutes held on 2/11/21, 4/16/21, 7/9/21, and 10/13/21 revealed documentation of ongoing observation and education of staff on proper hand hygiene and correct PPE (personal protective equipment) use and will continue to assess departments and discuss specific needs with director. There was no documentation of a summary of the observation conducted, analysis of the data, specific identified opportunities for improvement, and specific initiated actions. There was no documentation of the trend with the department in which 3 of the 4 months below benchmark/goal was documented.

EI # 5 confirmed, during the facility IC program review on 12/2/21 at 3:14 PM, there was no documentation the hand hygiene and glove use observation data had been evaluated and analyzed, opportunities for improvement in staff hand hygiene adherence/performance had been identified and improvement actions when benchmark(s)/goal(s) were not met were initiated.

During an interview on 12/3/21 at 9:00 AM with EI # 5, EI # 1, Chief Executive Officer, and EI # 3, Director of Patient Care Services # 1, the surveyor summarized the surveyor's observations which included IC breaches in hand hygiene and glove use, injection practices, and environmental cleaning procedures in which employees were nonadherent with facility policy and Centers for Disease Control IC recommendations.

Based on review of the facility Infection Control (IC) program, Centers for Disease Control (CDC) and Prevention National Healthcare Safety Network (NHSN) Overview, facility policy, facility Infection Control Risk Assessment (ICRA) for 2021 and staff interviews the facility failed to implement and maintain an active, organization-wide program for identifying, reporting, investigating and controlling infections and communicable diseases which reflected the scope and complexity of the hospital services provided.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

CDC NHSN Overview
Dated: 1/21

...Surveillance Techniques

...the IP (Infection Preventionist) shall seek out infections during a patient's stay by screening a variety of data sources, such as laboratory, pharmacy, admission/discharge/transfer, radiology/imaging...as well as patient charts, including history and physical exam notes, nurses'/physicians' notes, temperature charts...Laboratory-based surveillance should not be used alone, unless all possible criteria for identifying an infection are solely determined by laboratory evidence (for example...MDRO/CDI (Multidrug-Resistant Organism and Clostridium Difficile Infection)...

Facility Policy Number: 1001
Subject: Infection Prevention and Control Program
Department: Infection Control
Reviewed/Revision Date: No date documented

Policy: Hale County Hospital's Infection Prevention and Control Program (IPCP) shall ensure that this organization develops, implements and maintains an active, organization-wide program for the prevention, control and investigation of infections and communicable diseases in order to reduce the risks of endemic and epidemic infections in patients, visitors and healthcare workers...

...The IPCP shall be based on risk assessments and prioritization of those risks which include:

...Treatment, care and services provided
Population served

...Infection Prevention and Control Committee (IPCC) and IP:

...The IP shall:

...Develop and maintain a system for identifying, reporting, investigating and controlling infections and communicable diseases.
Implement a system for identifying, reporting, investigating and controlling infections and communicable disease of patients and staff.
Prepare monthly reports for the IPCC.

The IPCP at Hale County Hospital shall incorporate and document the following on an ongoing basis:

...Surveillance shall be conducted to determine rate of infections so that trends can be identified and investigated, and appropriate prevention strategies can be initiated.

...Active Surveillance:

Monitoring patients and healthcare workers for acquisition of infection and/or colonization
...Conducting surveillance activities in accordance with infection control surveillance practices utilized by the CDC's NHSN and shall include infection detection, data collection and analysis, monitoring, and evaluation of preventive interventions.
Methods for obtaining and reviewing data on infections/communicable diseases selected for monitoring
...Measurements and analysis of infections and communicable diseases to identify any patterns or trends.

Certain infections shall be monitored regularly, including:

...HAIs (Healthcare Acquired Infections)...including catheter-associated urinary tract infections...
...Employee health infections/trends
Pneumonias...

Facility ICRA 2021

Risk: ...Notifiable Conditions/Emerging Infectious Disease...Risk Priority...6 (1-10 scale with the higher the score, the greater the priority)...Summary/Analysis...2020 Trends: COVID - 19...Recommendations/Goals...Reinforced education to staff regarding the importance of reporting diseases in a timely manner...Probability the Risk will Occur...4 (frequent)...

1. Review of the facility IC program was conducted on 12/2/21 at 3:14 PM with Employee Identifier (EI) # 5, IP. During the review, EI # 5 was asked for the documentation of the monthly reports prepared for the facility IPCC. EI # 5 verbalized he/she does not prepare monthly reports for the IPCC.

EI # 5 was asked to provide documentation of the types of infections monitored through the program. EI # 5 provided the surveyor with a paper titled "Reportable Culture Results" for inpatients only that listed VRE (Vancomycin Resistant Enterococcus)... Ceph R Klebsiella - CRE Klesbsiella - (Klebsiella Pneumoniae resistant to Ceftriaxone and Imipenem)...CRE Enterobacter (Carbapenem-resistant Enterobacteriaceae)...MDR Acinetobacter (Multidrug resistant Acinetobacter)...C-Diff (Clostridioides Difficile)...CRE E. Coli (Carbapenem-resistant Escherichia coli)...MRSA (Methicillin-resistant Staphylococcus Aureus)...positive MRSA blood Cx (culture). EI # 5 then provided the surveyor with a folder containing culture results obtained by the facility in 2021. There was no documentation the culture result data was further monitored, analyzed, and evaluated.

EI # 5 was asked for documentation of other types of infection monitored through the program other than the infections documented on the "Reportable Culture Results" paper. EI # 5 verbalized, she/he only monitors the cultures found on the "Reportable Culture Results" paper and no other surveillance method was used other than laboratory culture results.

EI # 5 was asked if there was documentation of the facility monitoring HAI's, including catheter-associated urinary tract infections, employee health infections, COVID -19 infections, and Pneumonia infections. EI # 5 verbalized there was no documentation of the facility monitoring HAI's, including catheter-associated urinary tract infections, employee health infections, COVID -19 infections, and Pneumonia infections.

EI # 5 did confirm during the interview the facility does perform urinary catherizations, treat and for care patients with COVID-19 and pneumonia. EI # 5 also confirmed there was no documentation in the facility IC program of employee health infections.

Based on review of the facility Infection Control (IC) Program, facility policy and staff interviews the facility failed to demonstrate coordination among all components of the hospital responsible for antibiotic use and resistance including the facility IC Program.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

Hale County Healthcare Authority Antimicrobial Stewardship Policy and Procedure
Reviewed/Revision Date: No date documented

Purpose: The purpose of these policy and procedures is to ensure the responsible administration of antibiotics and antimicrobial's throughout all of Hale County Healthcare Authority's (HCHA) facilities. HCHA will do so by adhering to and monitoring the proper use of antimicrobial's as resources allow. This includes selecting the appropriate agent, dose duration, and route of administration to prioritize patient outcome while minimizing antibiotic resistance.

Policy: ...The objective of this team will be to optimize and monitor antibiotic usage at HCHA. The team consists of:

...(Employee Identifier (EI) # 1, Chief Executive Officer identified) as the designated administrative champion.

(EI # 5, Infection Preventionist identified) as the designated antibiotic stewardship program and pharmacist leader.

X, MD (Medical Doctor) as the designated physician leader... (There was no documentation of a MD named)

1. Review of the facility IC program was conducted on 12/2/21 at 3:14 PM with Employee Identifier (EI) # 5, Infection Preventionist. Review of the facility IC Program revealed no documentation of the facility Antimicrobial Stewardship Program to include the proper use of antimicrobial's.

During the review of the facility IC program, EI # 5, who is designed as the antibiotic stewardship program leader per facility policy, was asked who the program leader for the facility was, EI # 5 stated, "(MD identified) I think." EI # 5 was asked if the facility had documentation of the use and resistance of antibiotic(s) throughout the facility departments and the IC program? EI # 5 stated, "no."

Based on review of the facility Antibiotic Stewardship Program, policy and staff interviews the facility failed to document the evidence-based use of antibiotics in all departments and services of the hospital

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

Hale County Healthcare Authority Antimicrobial Stewardship Policy and Procedure
Reviewed/Revision Date: No date documented

Purpose: The purpose of these policy and procedures is to ensure the responsible administration of antibiotics and antimicrobial's throughout all of Hale County Healthcare Authority's (HCHA) facilities. HCHA will do so by adhering to and monitoring the proper use of antimicrobial's as resources allow. This includes selecting the appropriate agent, dose duration, and route of administration to prioritize patient outcome while minimizing antibiotic resistance.

Policy: HCHA is committed to reducing antibiotic resistance and promote optimal antimicrobial usage for best patient outcomes...The objective of this team will be to optimize and monitor antibiotic usage at HCHA. The team consists of:

...(Employee Identifier (EI) # 1, Chief Executive Officer identified) as the designated administrative champion.

(EI # 5, Infection Preventionist identified) as the designated antibiotic stewardship program and pharmacist leader.

X, MD (Medical Doctor) as the designated physician leader... (There was no documentation of a MD named)

Procedure:

a. The HCHA Antimicrobial Stewardship Program Committee with (will) be responsible for the following:

...Meeting regularly to discuss stewardship outcomes.

b. The pharmacist leader will be responsible for the following:

Reviewing antibiotics for unnecessary duplicative therapy such as double anaerobic coverage.

Review for opportunities to step-down from IV (Intravenous) to PO (oral) therapy.

c. In accordance with the CDC (Centers for Disease Control and Prevention) Core Elements of Hospital Antibiotic Stewardship Program recommendations, all prescriber's will:

...Conduct antibiotic time-outs to review appropriateness of initial prescription by:

Assessing patient condition and facility needs after 48 hours.
Assessing laboratory culture results when they become available...

...d. In order to best track antibiotic use and resistance, HCHA will:

...Track the number of antibiotic time-outs to see if all opportunities to improve are being utilized.
Monitor number of antibiotic step downs for missed opportunities.
Record number of unnecessary duplicate therapies.
Monitor facility adherence to treatment recommendations for pneumonia, UTI (Urinary Tract Infections), and skin infections.

e. HCHA will report data on stewardship efforts in order to improve upon the Antimicrobial Stewardship Program in the following ways:

Preparing reports related to antibiotic use to become available to all stakeholders, no just providers.
Distributing data through staff memorandums and meetings...

1. Review of the facility Antibiotic Stewardship Program (ASP) was conducted on 12/2/21 at 3:14 PM with Employee Identifier (EI) # 5, Antibiotic Stewardship Program Leader and Infection Preventionist.

EI # 5 was asked to provide documentation of the facility ASP. EI # 5 provided the Pharmacy and Therapeutics meeting minutes dated 11/17/2020 which revealed documentation of "discussion and review of antimicrobial stewardship policy and procedure...Submission of preliminary policy and procedure for review. Athena (facility Electronic Medical Record system) has some capability to assist with certain aspects of the program. Need to discuss with Athena representatives the possibility of adding additional features. Education of medical and nursing staff should occur once all features are confirmed through Athena..."

EI # 5 confirmed during the review there was no additional documentation of communication and collaboration with the facility Antimicrobial Stewardship Program. EI # 5 also confirmed there was no documentation of antibiotic use were reviewed for unnecessary duplicative therapy such as double anaerobic coverage, opportunities to step-down from IV to PO therapy were reviewed, antibiotic use and resistance were tracked, including number of antibiotic time-outs, facility adherence to treatment recommendations for pneumonia, UTI, and skin infections, prepared reports related to antibiotic use and the program data was distributed through staff memorandums and meetings.

Based on review of the facility Antibiotic Stewardship Program, policy and staff interviews the facility failed to document improvements, including sustained improvements, in proper antibiotic use.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

Hale County Healthcare Authority Antimicrobial Stewardship Policy and Procedure
Reviewed/Revision Date: No date documented

Purpose: The purpose of these policy and procedures is to ensure the responsible administration of antibiotics and antimicrobial's throughout all of Hale County Healthcare Authority's (HCHA) facilities. HCHA will do so by adhering to and monitoring the proper use of antimicrobial's as resources allow. This includes selecting the appropriate agent, dose duration, and route of administration to prioritize patient outcome while minimizing antibiotic resistance.

Policy: HCHA is committed to reducing antibiotic resistance and promote optimal antimicrobial usage for best patient outcomes...The objective of this team will be to optimize and monitor antibiotic usage at HCHA. The team consists of:

...(Employee Identifier (EI) # 1, Chief Executive Officer identified) as the designated administrative champion.

(EI # 5, Infection Preventionist identified) as the designated antibiotic stewardship program and pharmacist leader.

X, MD (Medical Doctor) as the designated physician leader... (There was no documentation of a MD named)

Procedure:

a. The HCHA Antimicrobial Stewardship Program Committee with (will) be responsible for the following:

...Meeting regularly to discuss stewardship outcomes.

b. The pharmacist leader will be responsible for the following:

Reviewing antibiotics for unnecessary duplicative therapy such as double anaerobic coverage.

Review for opportunities to step-down from IV (Intravenous) to PO (oral) therapy.

c. In accordance with the CDC (Centers for Disease Control and Prevention) Core Elements of Hospital Antibiotic Stewardship Program recommendations, all prescriber's will:

...Conduct antibiotic time-outs to review appropriateness of initial prescription by:

Assessing patient condition and facility needs after 48 hours.
Assessing laboratory culture results when they become available...

...d. In order to best track antibiotic use and resistance, HCHA will:

...Track the number of antibiotic time-outs to see if all opportunities to improve are being utilized.
Monitor number of antibiotic step downs for missed opportunities.
Record number of unnecessary duplicate therapies.
Monitor facility adherence to treatment recommendations for pneumonia, UTI (Urinary Tract Infections), and skin infections.

e. HCHA will report data on stewardship efforts in order to improve upon the Antimicrobial Stewardship Program in the following ways:

Preparing reports related to antibiotic use to become available to all stakeholders, no just providers.
Distributing data through staff memorandums and meetings...

1. Review of the facility Antibiotic Stewardship Program (ASP) was conducted on 12/2/21 at 3:14 PM, with Employee Identifier (EI) # 5, Antibiotic Stewardship Program Leader and Infection Preventionist.

EI # 5 was asked to provide documentation of the facility ASP. EI # 5 provided the Pharmacy and Therapeutics meeting minutes dated 11/17/2020 which revealed documentation of "discussion and review of antimicrobial stewardship policy and procedure...Submission of preliminary policy and procedure for review. Athena (facility Electronic Medical Record system) has some capability to assist with certain aspects of the program. Need to discuss with Athena representatives the possibility of adding additional features. Education of medical and nursing staff should occur once all features are confirmed through Athena..."

EI # 5 confirmed during the review there was no additional documentation of communication and collaboration with the facility Antimicrobial Stewardship Program. EI # 5 also confirmed there was no documentation of antibiotic use were reviewed for unnecessary duplicative therapy such as double anaerobic coverage, opportunities to step-down from IV to PO therapy were reviewed, antibiotic use and resistance were tracked, including number of antibiotic time-outs, facility adherence to treatment recommendations for pneumonia, UTI, and skin infections, prepared reports related to antibiotic use and the program data was distributed through staff memorandums and meetings.

Based on review of the facility Infection Control (IC) program, Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) Overview, facility policies, facility Infection Control Risk Assessment (ICRA) for 2021 and staff interviews, it was determined the governing body failed to ensure systems were in place and operational for the tracking of all infection surveillance, prevention, and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities.

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

Findings include:

CDC NHSN Overview
Dated: 1/21

...Surveillance Techniques

...the IP (Infection Preventionist) shall seek out infections during a patient's stay by screening a variety of data sources, such as laboratory, pharmacy, admission/discharge/transfer, radiology/imaging...as well as patient charts, including history and physical exam notes, nurses'/physicians' notes, temperature charts...Laboratory-based surveillance should not be used alone, unless all possible criteria for identifying an infection are solely determined by laboratory evidence (for example...MDRO/CDI (Multidrug-Resistant Organism and Clostridium Difficile Infection)...

Facility Policy Number: 1001
Subject: Infection Prevention and Control Program
Department: Infection Control
Reviewed/Revision Date: No date documented

Policy: Hale County Hospital's Infection Prevention and Control Program (IPCP) shall ensure that this organization develops, implements and maintains an active, organization-wide program for the prevention, control and investigation of infections and communicable diseases in order to reduce the risks of endemic and epidemic infections in patients, visitors and healthcare workers...

...The IPCP shall be based on risk assessments and prioritization of those risks which include:

...Treatment, care and services provided
Population served

...Infection Prevention and Control Committee (IPCC) and Infection Preventionist:

...The Infection Preventionist shall:

...Develop and maintain a system for identifying, reporting, investigating and controlling infections and communicable diseases.
Implement a system for identifying, reporting, investigating and controlling infections and communicable disease of patients and staff.
Prepare monthly reports for the IPCC.

The IPCP at Hale County Hospital shall incorporate and document the following on an ongoing basis:

...Surveillance shall be conducted to determine rate of infections so that trends can be identified and investigated, and appropriate prevention strategies can be initiated.

...Active Surveillance:

Monitoring patients and healthcare workers for acquisition of infection and/or colonization
...Conducting surveillance activities in accordance with infection control surveillance practices utilized by the CDC's NHSN and shall include infection detection, data collection and analysis, monitoring, and evaluation of preventive interventions.
Methods for obtaining and reviewing data on infections/communicable diseases selected for monitoring
...Measurements and analysis of infections and communicable diseases to identify any patterns or trends.

Certain infections shall be monitored regularly, including:

...HAIs (Healthcare Acquired Infections)...including catheter-associated urinary tract infections...
...Employee health infections/trends
Pneumonias...

Facility ICRA 2021

Risk: ...Notifiable Conditions/Emerging Infectious Disease...Risk Priority...6 (1-10 scale with the higher the score, the greater the priority)...Summary/Analysis...2020 Trends: COVID - 19...Recommendations/Goals...Reinforced education to staff regarding the importance of reporting diseases in a timely manner...Probability the Risk will Occur...4 (frequent)...

1. Review of the facility IC program was conducted on 12/2/21 at 3:14 PM with Employee Identifier (EI) # 5, Infection Preventionist.

During the review, EI # 5 verbalized there was no documentation the facility monitored HAI's, including catheter-associated urinary tract infections, employee health infections, COVID -19 infections, and Pneumonia infections per the facility policy

EI # 5 verbalized the only infections monitored by the facility IC program were the multidrug resistant infections monitored through laboratory culture results and those culture results were placed in a folder. EI # 5 verbalized there was no documentation the multidrug resistant culture results and other potential infections at the facility were tracked by the facility IC program. EI # 5 verbalized there was no documentation the facility monitored antibiotic use activities.

EI # 5 verbalized there were no reports prepared for the IPCC.

Based on review of the facility Infection Control (IC) program, Centers for Disease Control (CDC) and Prevention National Healthcare Safety Network (NHSN) Overview, facility policies, facility Infection Control Risk Assessment (ICRA) for 2021, facility 2021 hand hygiene and glove use surveillance data and staff interviews, to was determined the Infection Preventionist (IP) failed to document the infection prevention and control program and it's surveillance, prevention and control activities.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

CDC NHSN Overview
Dated: 1/21

...Surveillance Techniques

...the IP (Infection Preventionist) shall seek out infections during a patient's stay by screening a variety of data sources, such as laboratory, pharmacy, admission/discharge/transfer, radiology/imaging...as well as patient charts, including history and physical exam notes, nurses'/physicians' notes, temperature charts...Laboratory-based surveillance should not be used alone, unless all possible criteria for identifying an infection are solely determined by laboratory evidence (for example...MDRO/CDI (Multidrug-Resistant Organism and Clostridium Difficile Infection)...

Facility Policy Number: 1001
Subject: Infection Prevention and Control Program
Department: Infection Control
Reviewed/Revision Date: No date documented

Policy: Hale County Hospital's Infection Prevention and Control Program (IPCP) shall ensure that this organization develops, implements and maintains an active, organization-wide program for the prevention, control and investigation of infections and communicable diseases in order to reduce the risks of endemic and epidemic infections in patients, visitors and healthcare workers...

...The IPCP shall be based on risk assessments and prioritization of those risks which include:

...Treatment, care and services provided
Population served

...Infection Prevention and Control Committee (IPCC) and IP:

...The IP shall:

...Develop and maintain a system for identifying, reporting, investigating and controlling infections and communicable diseases.
Implement a system for identifying, reporting, investigating and controlling infections and communicable disease of patients and staff.
Prepare monthly reports for the IPCC.

The IPCP at Hale County Hospital shall incorporate and document the following on an ongoing basis:

...Surveillance shall be conducted to determine rate of infections so that trends can be identified and investigated, and appropriate prevention strategies can be initiated.

...Active Surveillance:

Monitoring patients and healthcare workers for acquisition of infection and/or colonization
...Conducting surveillance activities in accordance with infection control surveillance practices utilized by the CDC's NHSN and shall include infection detection, data collection and analysis, monitoring, and evaluation of preventive interventions.
Methods for obtaining and reviewing data on infections/communicable diseases selected for monitoring
...Measurements and analysis of infections and communicable diseases to identify any patterns or trends.

Certain infections shall be monitored regularly, including:

...HAIs (Healthcare Acquired Infections)...including catheter-associated urinary tract infections...
...Employee health infections/trends
Pneumonias...

Facility ICRA 2021

Risk: ...Notifiable Conditions/Emerging Infectious Disease...Risk Priority...6 (1-10 scale with the higher the score, the greater the priority)...Summary/Analysis...2020 Trends: COVID - 19...Recommendations/Goals...Reinforced education to staff regarding the importance of reporting diseases in a timely manner...Probability the Risk will Occur...4 (frequent)...

1. Review of the facility IC program was conducted on 12/2/21 at 3:14 PM with Employee Identifier (EI) # 5, IP, revealed documentation the IC program was monitoring hand hygiene and glove compliance through observation. Review of the documentation from the facility hand hygiene and glove compliance revealed documentation of the department monitored, what was monitored for each department staff and the results, and the overall percentage of compliance for the month. There was no documentation the IP evaluated and analyzed the data, identified opportunities for improvement in staff hand hygiene adherence/performance and initiated improvement actions when benchmark(s)/goal(s) were not met.

During the review, EI # 5 verbalized there was no documentation the facility monitored HAI's, including catheter-associated urinary tract infections, employee health infections, COVID -19 infections, and Pneumonia infections per the facility policy

EI # 5 verbalized the only infections monitored by the facility IC program were the multidrug resistant infections monitored through laboratory culture results and those culture results were placed in a folder. EI # 5 verbalized there was no documentation the multidrug resistant culture results and other potential infections at the facility were tracked by the facility IC program. EI # 5 verbalized there was no documentation the facility monitored antibiotic use activities.

EI # 5 verbalized there were no reports prepared for the IPCC.

Based on review of the facility Infection Control (IC) Program, facility policy and procedure and staff interview the facility Infection Preventionist (IP) failed to demonstrate communication and collaboration with the facility Antimicrobial Stewardship program.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

Hale County Healthcare Authority Antimicrobial Stewardship Policy and Procedure
Reviewed/Revision Date: No date documented

Purpose: The purpose of these policy and procedures is to ensure the responsible administration of antibiotics and antimicrobial's throughout all of Hale County Healthcare Authority's (HCHA) facilities. HCHA will do so by adhering to and monitoring the proper use of antimicrobial's as resources allow. This includes selecting the appropriate agent, dose duration, and route of administration to prioritize patient outcome while minimizing antibiotic resistance.

Policy: ...The objective of this team will be to optimize and monitor antibiotic usage at HCHA. The team consists of:

...(EI # 5, Infection Preventionist identified) as the designated antibiotic stewardship program and pharmacist leader.

X, MD (Medical Doctor) as the designated physician leader... (There was no documentation of a MD named)

Procedure:

a. The HCHA Antimicrobial Stewardship Program Committee with (will) be responsible for the following:

...Meeting regularly to discuss stewardship outcomes.

1. Review of the facility IC program was conducted on 12/2/21 at 3:14 PM with Employee Identifier (EI) # 5, IP. Review of the facility IC Program revealed no documentation of the facility Antimicrobial Stewardship Program to include the proper use of antimicrobial's.

During the review of the facility IC program, EI # 5, (who is designed as the antibiotic stewardship program leader per facility policy) was asked who the program leader for the facility was, EI # 5 stated, "(MD identified) I think."

EI # 5 was asked if the facility had documentation of communication and collaboration with the facility Antimicrobial Stewardship Program. EI # 5 provided the Pharmacy and Therapeutics meeting minutes dated 11/17/2020 which revealed documentation of "discussion and review of antimicrobial stewardship policy and procedure...Submission of preliminary policy and procedure for review. Athena (facility Electronic Medical Record system) has some capability to assist with certain aspects of the program. Need to discuss with Athena representatives the possibility of adding additional features. Education of medical and nursing staff should occur once all features are confirmed through Athena..."

EI # 5 confirmed there was no additional documentation of communication and collaboration with the facility Antimicrobial Stewardship Program.

Based on review of the Employee Files, Job Descriptions and interviews with the staff it was determined the facility failed to ensure the staff completed the Emergency Preparedness (EP) training initially and every 2 years.

Findings include:

Hale County Health Care Authority
Facility Wide Orientation Program
Date: January 21.2019

To: All Employees

Hale County Hospital will be having orientation on the following:

...Emergency Preparedness...

The following is a list of Months that the orientation will take place. The days will be announced at the beginning of each month: March, May, June and July.

Registered Nurse (RN) Job Description
Last Revision Date: December 2021

This job description covers the most significant duties performed...

Summary:

The Registered Nurse is responsible for the delivery of quality patient care through the nursing process of assessment, diagnosing, planning, implementation and evaluation.

Additional Responsibilities:

1. Responsible for attending staff meetings...

2. Attends in-service and mandatory meetings.

Licensed Practical Nurse (LPN)
Last Revision Date: December 2021

Summary:

The Licensed Practical Nurse assumes the responsibility for direct nursing care of assigned patients under the supervision of a Registered Nurse or physician in the patient care area.

Additional Responsibilities:

1. Responsible for attending staff meetings...

2. Attends in-service and mandatory meetings.

1. Review of the employee files revealed no documentation of Emergency Preparedness (EP) Training every 2 years on the following employee's:

Employee Identifier (EI) # 6, RN, EI # 7, Emergency Department Technician, and EI # 15, Registered Radiology Technologist, received initial EP training in March 2019. There was no documentation of EP training following March 2019.

EI # 5, Licensed Practical Nurse/Infection Preventionist, received initial EP training in May 2019. There was no documentation of EP training following May 2019.

EI # 17, Dietary Aide, received initial EP training in June 2019. There was no documentation of EP training following June 2019.

EI # 9, RN, and EI # 16, Dietary Manager, received initial EP training in July 2019. There was no documentation of EP training following July 2019.

There was no documentation of EP training, initially and every 2 years, on the following employees:

EI # 11, RN, who was hired on 12/15/1999.

EI # 12, Licensed Practical Nurse, who was hired 10/17/19.

EI # 14, Laboratory Technician, who was hired on 5/13/21.

An interview was conducted on 12/3/21 at 9:30 AM with EI # 3, Director of Patient Care Services # 2, who confirmed the Emergency Preparedness training was not done and should be completed every 2 years.

A second interview was conducted on 12/3/21 at 11:10 AM with EI # 18, CFO/HR (Chief Financial Officer/Human Resources), who stated there was no policy for EP training, but confirmed it was hospital practice for EP training to be completed during orientation, and annually after orientation, and it was not done.