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Based on medical record review, policy and procedure review, and staff interview, the facility failed to ensure two (2) of 10 patient's records reviewed contained documented evidence of Patient #3 and #7 having been informed of their patient's rights, in advance of furnishing or discontinuing patient care.


Findings Include:


Record review for Patient #3 and #7 revealed no documented evidence of the patient having been informed of his/her patient's rights, in advance of furnishing or discontinuing patient care.


Review of the facility's "Patient Bill of Rights" statement revealed no evidence of when or if a patient is to be informed of their patient's rights.


During an interview on 10/05/16 at 1:45 p.m. the Director of Nursing (DON) stated the facility did not have any other policy for patient's rights and confirmed that Patient #3 and #7's records had no documented evidence of the patient having been informed of their patient's rights, in advance of furnishing or discontinuing patient care.

On 10/05/16 at 3:30 p.m. these findings were discussed during exit conference. No additional documentation was submitted.

Based on medical record review, policy and procedure review, and staff interview, the facility failed to ensure four (4) of 10 patient's reviewed had documented evidence of the patient having been informed of their right to formulate advance directives. (Patient #1, #2, #3, and #7)


Findings Include:


Record review for Patient #1, #2, #3 and #7 revealed no documented evidence the patients were informed of their right to formulate advance directives.

Review of the facility's "Advance Directives" policy, revised January 16, 2016 and approved March 4, 2016, revealed, "Scope: This policy applies to all of (Facility) Admissions and Business Office Staff. Purpose: The purpose of this policy is to establish a process by which patients will be questioned about Advance Directives during each admission. Policy Detail: Patients will be questioned about the presence of Advance Directives on every inpatient admission. 1. Patients admitted through Admissions: A. The admissions clerk asks the patient whether they have formulated an Advance Directive: Individual Instructions or Power of Attorney for Healthcare, recognizing that patients may use the term "Living Will". a. If yes, this is noted on the admission form and in the system ...The admission clerk stamps the front sheet noting that they do have an Advance Directive. b. If the patient says no, they have no formulated Advance Directive, this is noted in the admission form ...2. Patients Admitted After Hours. A. The registered nurse initial assessment, the patient is asked about Advance Directives and the nurse documents the substance of the patient's wishes on the Assessment Form ...".


During an interview on 10/05/16 at 1:45 p.m. the Director of Nursing confirmed there was no documented evidence Patient #1, #2, #3 and #7 were informed of their right to formulate an Advance Directive.

On 10/05/16 at 3:30 p.m. these findings were discussed during exit conference. No additional documentation was submitted.

Based on medical record review, policy and procedure review, and staff interview, the facility failed to ensure that the nursing staff developed, and kept current, a nursing care plan for Patient #5, #6, #8 and #10, four (4) of 10 patients reviewed.

Findings Include:


Record review for Patient #5, #6, #8 and #10 revealed no documented evidence of a nursing care plan in their chart.


During an interview on 10/05/16 at 1:45 p.m. the Director of Nursing confirmed that there was no documented evidence of a nursing care plan for Patient #5, #6, #8 and #10.


Review of the facility's "Initial and Nursing Assessment" policy (effective April 13, 1999 and last reviewed July 20, 2016) revealed "Admission Assessment Policy: Early identification of patient's care needs is essential for the quality of care in the population we serve. The Admission Assessment is done by a Registered Nurse, in a timely manner ensuring early intervention for identified problems. The documented assessment is the basis for further assessment and to determining the plan of care ...Assessment Process: Patient problem prioritizing is always a consideration, complete assessment is performed within 24 hours of admission ...".

On 10/05/16 at 3:30 p.m. these findings were discussed during exit conference. No additional documentation was submitted.

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure outdated or otherwise unusable drugs and biological were not available for patient use during two (2) of two (2) days of survey.


Findings Include:


Observation of the Newborn Nursery and Birthing Room, made with the Nurse Educator on 10/04/16 from 9:30 a.m. to 11:15 a.m., revealed that the the crash cart check list was found on top of a crash cart located in the Newborn Nursery. Review of this document revealed no documented evidence that the crash cart was checked by the Registered Nurses (RNs) from 08/11/16 through 10/04/16.
Observation revealed expired items in the crash cart:
1. Two (2) bags of Sodium Chloride 50 milliliters (ml) - expired 01/16;
2. Two (2) bags of 5% Dextrose with 0.2% Sodium Chloride 25% IV (intravenous fluid) - expired 10/15 and 4/16; and
3. Two (2) ampules of Narcan 0.4 mg (milligram) (IV medication used to reverse the effects of narcotics) - expired 1/01/16.
Observation of the emergency medication box in the Birthing Room revealed two (2) ampules of Narcan 0.4 mg which had expired on 1/01/16.
During these observations the Nurse Educator revealed she did not know that the ampules of Narcan had expired.


Review of the facility's "Crash Cart" policy (approved 9/19/14) revealed: "Purpose: To provide equipment and medications on crash carts or in emergency boxes in designated area for emergency care ...
Policy: ...Safety checklists will be completed by nursing units each shift and by other ancillary units once a day.
Procedure: The crash cart will be checked daily as indicated above, for security. The safety sign-out sheet will be checked to indicate that: (a) the cart or box is locked (b) the defibrillator is functioning (c) the medications are in date (d) the date, time and initials of the person checking the cart are documented ... Emergency Crash Carts are located: Newborn Nursery ...
Emergency medication boxes are located: Labor and Delivery area ..."


On 10/05/16 at 3:30 p.m. during exit conference the above concerns were discussed. No additional documentation offered.

Based on observation, review of the manufacturer's instructions, policy review, and staff interview, the facility failed to:
1. ensure the Newborn Nursery Department provided a sanitary environment to avoid sources and transmission of infections and communicable diseases during two (2) of two (2) days of survey; and
2. ensure respiratory staff and nursing staff followed manufacturer's guidelines for patient care and safety from infection during two (2) of two (2) days of survey.


Findings Include:

Observation in the Newborn Nursery/Birthing Room, made with the Nurse Educator on 10/04/16 from 9:30 a.m. to 11:15 a.m., revealed:
1. One new born isolette had a brown fluid along the side of the left isolette's assess door; four (4) loose black colored hairs and debri which was brownish in color covered the inside of the isolette; three (3) pieces of torn disposable alcohol paper wipes were under the isolette mattress; right and left access doors had finger prints noted over the outside surface; and the isolette was covered with dust.
2. One new born isolette had three (3) black hairs under the mattress pad and the outside was covered with dust.
3. The newborn nursery weight scales were located on a wooden cabinet which had white paint peeling off the entire top of the cabinet. A pink colored wash basin located under the cabinet contained a partially used tube of Erythromycin Ophthalmic (eye) Ointment 0.5 % 5mg (milligram). The side of the tube read, "Do not reuse once opened. Discard." The Nurse Educator removed the basin and stated, "We save the unused Erythromycin for a doctor to take to another country when he goes on his mission trips. Old habits die hard."
4. The Birthing Room bathroom shower area contained four (4) rolls of unused toilet paper, cleaning supplies, and six (6) manuals.
The Nurse Educator confirmed all of these observations and stated, "I was aware that the nursery did have a lot of infection control issues. Maybe this survey will get the attention of the hospital to do something about these problems. The nursery used to be a patient room."


Review of the facility's "Infection Control Guideline" policy (undated) revealed: "Warmers (Isolette for newborns) are to be cleaned as in discharge cleaning after each use. They are also to be covered with a clean sheet and stored in the northeast corner of the nursery until further use."

Review of the facility's "Infection Control Guideline" policy (undated) revealed: "Cleaning of the nursery area: the nursery furnishings, surfaces, and equipment must be clean at all times. Remember to clean items that come in contact with more than one baby, between each baby ...".


Review of the facility's "Infection Control Policy Newborn Nursery" (undated) revealed: "The Newborn Nursery is a unique area for the care of infants in the hospital. Infants are highly susceptible to infections and therefore require methods of prevention and technique of care different from adults... 4e. ...Isolettes: (1.) will be damp dusted with a germicide solution every eight (8) hours by the nursing staff. (2.) Will be rotated every seven (7) days. (3.) Will be terminally cleaned by housekeeping post-discharge ...".


Review of "Infection Control Guidelines Obstetrical Unit" (undated) revealed: "B. ...5. The Infection Control Nurse Surveillance will assist in preparation and presentation of educational relevant to all aspects of infection control.... C. .1 The Infection Control Nurse Committee will 1. Review and approval of all policies and practices relevant to infection control in the obstetrical areas... The Infection Control Committee will ...2. Review of data, concerning infections, special studies and environmental cultures in the obstetrical areas, for detection and action towards outbreaks of infection or hazardous practices."

During an interview on 10/05/16 at 1:00 p.m. the Respiratory Director stated, "The Christmas Tree Oxygen adapters we use are multi-use for multiple patients."

In an interview on 10/05/16 at 1:05 p.m. the Administrator stated they were not aware the Christmas Tree devices were one time use. He stated, "We will fix it."

Review of the manufacturer's guidelines (revised July, 2008) for Christmas Tree Oxygen adapters revealed, "Nipple & Nut Standard DISS 1240 oxygen fitting... Single Patient use. Do not sterilize..."

On 10/05/16 at 1:55 p.m. observation revealed 35 used Christmas Tree Oxygen adapters which the Respiratory Director removed from use in the hospital.

Review of the facility's "Oxygen Therapy" policy (effective date 01/2015; revision date 01/2016) revealed, "...Purpose - The purpose of this policy is to extablish criteria and standards for the administration of Oxygen Therapy.... Procedure... 2. Obtain necessary equipment: A. Oxygen delivery device (i.e. cannula, mask, etc.) B. Flowmeter...."
There was no evidence in the policy regarding the oxygen connectors being for single patient use.

On 10/05/16 at 3:30 p.m. these findings were discussed during exit conference. No additional documentation was submitted.


22336

Based on observation, review of the manufacturer's instruction, policy and procedure review, and staff interview, the facility's infection control officer failed to ensure respiratory and nursing staff followed manufacturer's guidelines for patient care and safety from infection and communicable diseases of patients and failed to ensure the Newborn Nursery Department provided a sanitary environment to avoid sources and transmission of infections and communicable diseases during two (2) of two (2) days of survey;

Findings Include:

Cross Refer to A0747 for the facility's infection control officer's failure to ensure respiratory and nursing staff followed manufacturer's guidelines for patient care and safety from infection and communicable diseases of patients and to failure to ensure the Newborn Nursery Department provided a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Based on staff interview, policy and procedure review, Organ and Tissue Donation Cooperative Agreement review, and review of Recovery Access Agreement, Mississippi Organ Procurement Agency (MORA) reports, the facility failed to ensure that the organ, tissue, and eye procurement requirements are met.



Findings Include:


Review of the facility's documentation regarding Organ and Tissue Donation revealed that in December 2015 their Referral Compliance Rate was 88%. Documentation showed that there was a death on 12/18/15 which was not referred to MORA; Two (2) cardiac deaths were reported to MORA greater than one (1) hour after the time of the deaths; One (1) death in April 2016 was called to MORA greater than one (1) hour after the cardiac time of death, and one (1) death in May 2016 was called to MORA greater than one (1) hour after the cardiac time of death.


During an interview on 9/5/16 at 2:00 p.m. the Director of Nurses stated, "A Registered Nurse (RN) was responsible for reporting these deaths to MORA in the appropriate time. The RN was terminated from this hospital on 1/22/16." No further information was provided.


Review of the facility's "Recovery Access Agreement" (July 1, 2014) between the facility and the ....Eye Bank revealed: "(the Eye Bank) provides services relating to the recovery, testing, processing, storage and distribution of eyes (corneas and sclera).... 1. The hospital will provide referrals of potential donors of the above tissues to (the ...Eye Bank).


Review of the facility's undated "Organ & Tissue Donation Cooperative Agreement" revealed responsibilities of the hospital included "...7. Timely referral of all expired patients, within one hour of cardiac death, to MORA referral line. MORA shall then be responsible for the evaluation of the patient as a potential tissue donor ...".


Review of the facility's "Organ and Tissue Donation" policy (revised 11/24/14; reviewed 7/20/16) revealed: "Policy: It is the policy of ...Hospital to provide the option of organ, eye and tissue donation to the family members of deceased patients... Families of every deceased patient determined to be medically suitable for organ, eye or tissue donation by MORA and the ....Eye Bank will routinely be afforded the opportunity to authorize to donate to MORA... Procedure: 1. Refer all deaths to MORA and the ...Eye Bank via the Donor Referral Line.... a. Criteria: i. Imminent Death:... ii. Cardiac Death:... 2. No potential donor should be ruled unsuitable for donation before the patient is referred to MORA. Appropriate screening to determine medical suitability for donation will be done by MORA ... "

On 10/05/16 at 3:30 p.m. these findings were discussed during exit conference. No additional documentation was submitted.

Based on staff interview, the facility failed to provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident directed by a qualified professional.


Findings Include:


During an interview on 10/04/16 at 11:21 a.m. the Director of Nursing (DON) stated, "The Swing Bed Coordinator does not have any specialized training or education for providing activities to Swing Bed residents. She is a Registered Nurse." When the DON was asked for Swing Bed Policies and Procedures, she stated that the facility does not have any.


During an interview on 10/04/16 at 2:00 p.m. the Swing Bed Coordinator stated that neither she nor any other employee providing activities to Swing Bed residents had any specialized training or education for providing activities to Swing Bed residents.


On 10/05/16 at 3:30 p.m. these findings were discussed during exit conference. No additional documentation was submitted.