HospitalInspections.org

Based on review of CAH policies and personnel records and staff interview the CAH staff failed to ensure measures for screening and evaluating health care worker staff with patient contact for communicable and non-treated communicable diseases for 11 of 15 (Staff A-K) healthcare personnel. The CAH had a census of 8 patients.

Failure to screen and evaluate CAH staff could potentially expose patients to communicable diseases of disseminating infectious agents.

Findings included:

1. Review of personnel records revealed: Staff A-K (11 of 15) lacked health examinations and/or TB screening tests.

2. Review of the CAH Employee Heath Program undated revealed: Employee health screens are required on all associates every four years. The health form is completed by the associate. Any abnormal results are then addressed with the associate to follow up with their physician. TB test results are updated as needed to meet the requirement.

3. During an interview on 3/17/2010 at 9:30 AM the Employee Health Manager said the employee health screens and TB tests were not current for the CAH staff. CAH staff had identified this concern and has a plan in place to update all employee health screens and TB tests. The plans were taken to a Department Managers meeting 3/16/10.

Based on medical record review and staff interview, Contracted Service's A (CSA) failed to develop and/or implement policies and procedures that delineated the parameters for staff to follow when monitoring equipment readings on the portable RO (reverse osmosis) machine, and failed to ensure that all staff document chlorine checks when running the RO machine daily per manufacturer's recommendations (it is important to run the RO machine daily, even if there are no patients, to prevent water stagnation that can cause bacterial growth).

Failure to provide staff with parameters indicating normal and abnormal readings could cause potential equipment failure and subsequent patient harm.

Failure to follow manufacturer's recommendations when performing daily maintenance of the RO unit could lead to equipment failure.

The CAH had an acute hemodialysis patient census of 3 at the time of survey. The current 3 hemodialysis patients received dialysis treatments in the chronic dialysis unit attached to the CAH.

Findings include:

1. Review of manufacturer's recommendations titled "ZYZATECH WATER SYSTEMS, INC. MILLENIUM REVERSE OSMOSIS UNIT OPERATION AND MAINTENANCE MANUAL", dated 29 Mar-02, stated, in part, "...Daily Maintenance...observe and record the Chlorine/Chloramine concentrations in the pretreatment log...Weekly Maintenance...observe and record the waste and product flow rates...measure and record the feed water temperature..Take corrective action...if any pretreatment devise falls out of normal parameters or failes to provide adequate treatment of feed water...before continuing with use of the RO unit..."

2. Review of a document titled "MILLENIUM CLEAN/DISINFECTION LOG" showed completion of all areas to be measured and recorded per manufacturer's recommendations. However, further review failed to identify normal parameters for staff to follow as a guideline in knowing if a reading fell from the normal range.

3. During an interview on 3/17/10 at 10:55 AM, CSA Staff CSA DD, Support Services Coordinator, verbalized agreement that there should be parameters on the daily log. At that time Staff DD presented a newly created form which included parameters for staff to follow when documenting equipment readings.

4. . Review of a document titled "MILLENIUM RO MACHINE DAILY STARTUP LOG" showed completion of all areas to be measured and recorded per manufacturer's recommendations. However, further review lacked documentation of the chlorine/chloramine check required per manufacturer's recommendations.

5. During an interview on 3/17/10 at 11:05 AM, the Support Services Coordinator verified staff failed to check the chlorine/chloramine checks daily per rmanufacturer's recommendations. At that time Staff DD presented a newly created form which included chlorine/chloramine checks.

Based on review of policies and procedures, medical record review, and staff interview Contracted Services A (CSA) failed to ensure staff completed the Communication Handoff Form in its entirity as per policy and procedure. The CAH had an acute dialysis patient census of 3 at the time of the survey.

Failure to complete the document in its entirity leaves the medical record incomplete.

Findings for 3 of 3 inpatient records reviewed (Patient #'s 1, 2, and 3) and for 4 of 4 closed records reviewed(Patient #'s 4, 5, 6, and 7) include:

1. The CAH had a policy titled "Southeastern Renal Dialysis, Policy: Hand off Communication", dated August 2008, which stated, in part, ".... Hand off to Acute Care In-Patient Facility: Hand off communication will occur between the dialysis nurse and the hospital RN before and after dialysis. A handoff communication form will be completed to include signatures of both nurses and will be part of the medical record..."

2. Review of the medical record for Patient #1 revealed the following:

Review of a handoff communication form titled "Dialysis Patient Transfer", dated 3/15/10, showed an RN (Registered Nurse) signature by the nurse transporting the patient, however failed to show an RN signature from the nurse receiving the patient.

3. Review of the medical record for Patient #2 revealed the following:

Review of a handoff communication form titled "Dialysis Patient Transfer", dated 3/15/10, showed an RN (Registered Nurse) signature by the nurse transporting the patient, however failed to show an RN signature from the nurse receiving the patient.

4. Review of the medical record for Patient #2 revealed the following:

Review of a handoff communication form titled "Dialysis Patient Transfer", dated 3/16/10, showed an RN (Registered Nurse) signature by the nurse transporting the patient, however failed to show an RN signature from the nurse receiving the patient.

5. Review of the medical record for Patient #3 revealed the following:

Review of a handoff communication form titled "Dialysis Patient Transfer", dated 3/15/10, showed an RN (Registered Nurse) signature by the nurse transporting the patient, however failed to show an RN signature from the nurse receiving the patient.

6. Review of the medical record for Patient #4 revealed the following:

Review of a handoff communication form titled "Dialysis Patient Transfer", dated 3/16/10, showed an RN (Registered Nurse) signature by the nurse transporting the patient, however failed to show an RN signature from the nurse receiving the patient.

7. Review of the medical record for Patient #5 revealed the following:

Review of a handoff communication form titled "Dialysis Patient Transfer", dated 12/9/09 and 12/11/09, showed an RN (Registered Nurse) signature by the nurse transporting the patient, however failed to show an RN signature from the nurse receiving the patient.

8. Review of the medical record for Patient #6 revealed the following:

Review of a handoff communication form titled "Dialysis Patient Transfer", dated 1/22/10 and 1/25/10, showed an RN (Registered Nurse) signature by the nurse transporting the patient, however failed to show an RN signature from the nurse receiving the patient.

9.Review of the medical record for Patient #7 revealed the following:

Review of a handoff communication form titled "Dialysis Patient Transfer", dated 2/3/10 and 2/5/10, showed an RN (Registered Nurse) signature by the nurse transporting the patient, however failed to show an RN signature from the nurse receiving the patient.

10. During an interview on 3/16/10 at 3:45 PM, CSA Staff DA, Nurse Manager, and Staff RN DB acknowledged staff failed to complete the medical record with signatures. Staff DB stated, "Yes, that is right. The policy does require both nurses to sign the form."

Based on policy review, record review and staff interview, the CAH failed to ensure that the plan of care developed by an interdisciplinary team included documentation of participation by the attending physician for 1 of 3 open ( # 1) and 5 of 5 closed swing bed medical records (#2, 3, 4, 5, and 6). The CAH had a census of three skilled patients.

Failure to provide an activity program that meets the physical and psychosocial needs of the individual patient has the potential to impede the physical and psychological well being of each patient.

Findings included:

1. Review of Henry County Health Center Skilled Nursing Care Policy entitled "Swing Bed Discharge Planning" approved 10/24/2006 stated " Bi-weekly interdisciplinary patient reviews are conducted to prepare the patient and family for discharge and to provide individualized patient care. Continuity of care needs and progress toward rehabilitation goals are identified with resolutions sought and barriers to discharge resolved through correlation of services provided by the interdisciplinary team members. Home environment, special needs, referral services and discharge goals are identified with the patient. These goals are realistic, measurable, and consistent with the therapy and instructions of the physician.."

2. Review of the open medical record and plan of care for Patient #1 admitted 3/11/10 to the swing level of care with a diagnoses of pneumonia, vomiting, diarrhea, hypoxia, hypoxia,hyponatremia revealed no documented evidence of physician involvement in development of the Multi-Disciplinary Plan of Care imitated on 3/15/10.

3. Review of the closed medical record and plan of care for Patient #2 admitted 3/3/10 to the swing level of care with a diagnoses of Left Acute Hemorrhagic stroke, uncontrolled hypertension, degenerative hypertension, and degenerative arthritis and discharged on 3/8/10 revealed no documented evidence of physician involvement in development of the Multi-Disciplinary Plan of Care imitated on 3/4/10 with review on 3/8/10.

4. Review of the closed medical record and plan of care for Patient #3 admitted 2/19/10 to the swing level of care with a diagnoses of Respiratory distress with compromise of oxygenation early pneumonia, severe Chronic Obstructive Pulmonary Disease and discharged on 2/25/10 revealed no documented evidence of physician involvement in development of the Multi-Disciplinary Plan of Care imitated on 2/22/10.

5. Review of the closed medical record and plan of care for Patient #4 admitted 2/26/10 to the swing level of care with a diagnoses of uremia, hypothyroidism,pneumonia,urinary tract infection, coronary artery disease, congestive heart failure, malnutrition, anemia, sacral gluteal ulcers and discharged on 3/6/10 revealed no documented evidence of physician involvement in development of the Multi-Disciplinary Plan of Care imitated on 3/1/10 with review on 3/4/10.

6. Review of the closed medical record and plan of care for Patient #5 admitted 2/16/10 to the swing level of care with a diagnoses of chronic obstructive pulmonary disease, pneumonia, oral thrush, gastroesophageal reflux disease and discharged on 2/26/10 revealed no documented evidence of physician involvement in development of the Multi-Disciplinary Plan of Care imitated on 10/1/09 with review on 2/18/10 with review on 2/22/10 and 2/25/10.

7. Review of the closed medical record and plan of care for Patient #6 admitted 2/23/10 to the swing level of care with a diagnoses of intractable back and leg pain,severe degenerative arthritis, Bechert syndrome, diabetes, left ventricular hypertrophy, acute urinary retention, bronchitis and discharged on 3/4/10 revealed no documented evidence of physician involvement in development of the Multi-Disciplinary Plan of Care imitated on 2.25.10 with review on 3/1/10 and 3/3/10.

8. During an interview on 3/15/10 at 3:25 PM Staff L (Licensee Social Worker) acknowledged the Interdisciplinary Care Conferences lacked documentation of physician participation and signature of the Interdisciplinary Progress Report. Staff L stated "The physicians know about the care conferences and may ask to relay a piece of information in the conference but they do not attend or sign off on the progress report".