HospitalInspections.org

Based on review of medical records (MR), hospital policy and procedure, and staff interview, it was determined the facility failed to ensure two of four swing bed patients were informed of the patient's rights prior to receiving care at the facility. This affected Patient Identifier (PI) # 17 and PI # 18 and had the potential to affect all patients served by this facility.

Findings include:

Hospital Policy: Patient Rights and Responsibilities
Policy Number: Not documented
Date Issued: Not documented

...Procedure:

1. As a part of the orientation process, patients or family members, significant and/or concerned others will be informed both orally and in writing of their rights by the Admission Nurse and/or the Care Manager.

...3. A copy of the Patient's Rights form will be given to the patient, family member, significant others, and/or concerned others as part of the orientation packet.

1. PI # 17 was admitted to the hospital swing bed unit on 1/6/24 with diagnoses including Cerebral Infarction/Multiple Brain Lesions with Hemorrhage into at Least One of these Lesions and Poor Balance with Diminished Mentation.

Review of the MR revealed no documentation the patient, family member, significant and/or concerned others were informed orally and in writing of the patient rights.

An interview was conducted on 1/11/24 at 9:18 AM with Employee Identifier (EI) # 2, Case Management Director, who confirmed there was no documentation the patient, family member, significant and/or concerned others were informed orally and in writing of the patient rights.

2. PI # 18 was admitted to the hospital swing bed unit on 1/9/24 with diagnoses including Pneumonia and Congestive Heart Failure.

Review of the MR revealed no documentation the patient, family member, significant and/or concerned others were informed orally and in writing of the patient rights.

An interview was conducted on 1/11/24 at 9:36 AM with EI # 2 who confirmed there was no documentation the patient, family member, significant and/or concerned others were informed orally and in writing of the patient rights.

Based on observations and staff interviews, it was determined the hospital failed to ensure the Senior Care Unit was free of ligature risks.

This deficient practice had the potential to negatively affect all patients admitted to the Senior Care Unit.

Findings include:

1. During a tour of the Senior Care Unit on 1/9/24 at 10:30 AM with Employee Identifier (EI) # 3, Chief Nursing Officer, the following ligature risks were identified:

The activity room bathroom door was lockable from the inside. In the bathroom, the toilet and sink plumbing were exposed and the grab rail was not enclosed, creating ligature risks.

An interview was conducted on 1/9/24 at 11:00 AM with EI # 3 who confirmed the bathroom was used by all patients on the unit and the items identified could be used to attach ligature.

Based on review of the facility QAPI (Quality Assurance and Performance Improvement) program documentation, facility policy and interviews, it was determined the facility QAPI program failed to include reporting data for each department of the facility.

This deficient practice had the potential to affect all patients admitted to this facility.

Findings include:

Facility Policy: Performance Improvement Plan
Policy Number: not documented
Policy Date: 1/12/23

I. Purpose: The Performance Improvement Plan for Wiregrass Medical Center establishes a planned, systemic, organization-wide approach to process design and performance measurement, analysis, and improvement for the health care services we provide.

...Objectives:

...B. To collect data to monitor the stability of existing processes, identify opportunities for improvement, identify changes that will lead to improvement, and sustain improvement.

C. To aggregate and analyze data on an ongoing basis...

F. To educate leaders and staff regarding responsibilities and effective participation in performance improvement activities...

XII. Unit/Program Activities: Units and/or programs will monitor, evaluate and improve functions and or services provided.

1. The Director/Manager is responsible for and actively participates in monitoring, evaluation and improvement activities for it's unit or program...

3. All departments shall implement a plan for improving performance for their assigned areas...

Report findings to Performance Improvement Committee on quarterly basis...

1. Review of the QAPI data for the year 2023 revealed no documentation of QAPI data from all hospital departments including Dietary, Rehabilitation Services and the inpatient Detox Program.

An interview was conducted on 1/9/24 at 1:50 PM with Employee Identifier (EI) # 6, Quality Director, who confirmed there was no data submitted for Dietary, Rehabilitation Services, and the Detox program and the three departments did not participate in the hospital QAPI program.

Based on review of medical records (MR), Potter and Perry Fundamentals of Nursing, facility policies and procedures, and interviews, it was determined the facility failed to ensure:

1. Wound care was provided as ordered by the physician.
2. Wounds were assessed daily to include measurement and a description as directed per policy.
3. Nursing staff documented a pain assessment and re-assessment after PRN (as needed) medications were administered for pain.
4. Daily weights were obtained as ordered by the physician.
5. Vital signs were assessed every five minutes times three, as directed per facility policy, for blood administration.
6. Nursing staff followed the physician's orders and drained the correct amount of fluid following a Paracentesis.
7. PRN (as needed) medications for elevated blood pressure were administered as ordered.

These deficient practices affected two of four MR's reviewed of patients with wounds including Patient Identifier (PI) # 24 and PI # 26, two of five inpatient MR's reviewed requiring a surgical procedure including PI # 28 and PI # 22 and had the potential to affect all patients treated at this facility.

Findings include:

Facility Policy: Wound Care/Treatment Guidelines
Policy Number: Not documented
Date Revised/Reviewed: 2/2019

...Purpose: To provide excellent wound care to promote healing.

Guidelines:
1. A daily assessment should be done on all wounds requiring treatment. This should include measurement and a description....

Potter and Perry Fundamentals of Nursing
Fifth Edition
Copyright 2001

...Chapter 47. Skin Integrity and Wound Care

...Acute Care. Management of Pressure Ulcers.

...When treating a pressure ulcer, the wound should be reassessed for location, stage, size, sinus tracts, undermining, tunneling, exudate, necrotic tissue, and the presence or absence of granulation, tissue and epithelialization...Pressure ulcers should be reassessed at least daily...

Hospital Policy: Pain Assessment
Policy Number: Not documented.
Review Date: 10/23

...Statement of Purpose: To develop a procedure to follow for assessment and treatment of pain.

Text: When (a) patient complains of pain, the licensed nurse will assess the patient. The nurse will document on the PRN Pain Assessment MAR (Medication Administration Record):

...4. Origin of pain or location of pain.
5. Severity (rate on scale of 0 - 10).
6. Response to treatment.

The above should be documented for each PRN pain medication given. PRN pain medications should be re-assessed within 1 (one) to 4 (four) hours depending on route of administration.

Hospital Policy: Blood Administration
Policy Number: Not documented.
Review Date: 3/21

...Statement of Purpose: To administer blood in the safest and most efficient way to obtain the greatest patient benefit possible.

...Vital signs:

...3. Vital signs will be checked and recorded every 5 minutes x (times) 3...

1. PI # 24 was admitted on 11/9/23 with diagnoses including Acute UTI (Urinary Tract Infection) with Leukocytosis, Dehydration, Diabetes Mellitus Type II with Hyperglycemia, Multiple Decubiti, and Failure to Thrive.

Review of the Initial Nursing Interview and Assessment dated 11/9/23 revealed documentation of a Stage 3 pressure ulcer to the right heel measuring 5.5 cm (centimeters) by 5.75 cm and a Stage 2 pressure ulcer to buttocks measuring 1.25 cm by 2.5 cm. There was no depth of the wounds documented.

Review of the physician's order dated 11/9/23 at 6:56 PM revealed orders for Bactroban ointment BID (twice daily). There was no location for the ointment application on the order.

Review of the physician's order dated 11/10/23 at 9:30 AM, post debridement of right heel, revealed orders to clean right heel with saline, pat dry, apply one half strength (Dakin's Solution) soaked 4 x 4 (four by four) to wound bed, dry four by fours, Kerlix, and tape BID.

Review of the physician's order dated 11/10/23 at 10:06 PM revealed orders for Dakin's Solution full strength, apply to right heel with dressing change BID.

Review of the Patient Progress Note (PPN) dated 11/11/23 at 9:40 AM and 9:30 PM revealed the nurse documented wound care to the right heel with 1/2 strength Dakin's solution and not the full strength Dakin's solution ordered.

Review of the PPN dated 11/12/23 at 10:30 AM revealed the nurse documented wound assessment and care to the right heel with 1/2 strength Dakin's solution and not the full strength Dakin's solution ordered.

Further review of the PPNs dated 11/12/23 revealed no measurements of the pressure ulcer to the buttocks.

Review of the PPN dated 11/13/23 at 9:45 AM and 9:14 PM revealed the nurse documented wound assessments and wound care to the right heel with 1/2 strength Dakin's solution and not the full strength Dakin's solution ordered.

Further review of the PPNs dated 11/13/23 revealed no documentation of an assessment of the pressure ulcer to the buttocks.

Review of the PPNs dated 11/14/23 at 10:55 AM and 9:10 PM revealed the nurse documented wound care to right heel with 1/2 strength Dakin's solution and not the full strength Dakin's solution ordered.

Further review of the PPNs dated 11/14/23 revealed no documentation an assessment of the pressure ulcer to the buttocks and no documentation of wound measurements of the pressure ulcer to the right heel.

Review of the PPN dated 11/15/23 at 10:00 AM revealed the nurse documented wound care to right heel with 1/2 strength Dakin's solution and not the full strength Dakin's solution ordered.

Further review of the 11/15/23 PPNs revealed no documentation of measurements of the pressure ulcer to the right heel and no documentation of an assessment of the pressure ulcer to the buttocks.

In an interview conducted on 1/11/24 at 3:40 PM, EI # 7, Director of Nursing, confirmed the staff failed to follow the physician's orders for wound care and failed to assess all wounds daily.



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2. PI # 28 was admitted to the hospital on 1/4/24 with a diagnosis of Cellulitis and Abscess of the Left Axilla Extending into the Left Chest Wall and Left Breast.

Review of the Physician Admission Orders dated 1/4/24 revealed an order for IV (Intravenous) Morphine 4 mg (milligrams) every four hours prn for pain.

Review of the PPN dated 1/4/24 revealed at 10:12 PM, the nurse documented the patient was administered Morphine 4 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

Review of the Physician Orders dated 1/5/24 revealed an order for Norco (Hydrocodone and Acetaminophen) 5 mg/325 mg 1 tablet every four hours prn for pain and to only use Morphine if severe pain.

Review of the PPN dated 1/5/24 revealed:

At 3:11 AM, the nurse documented the patient was administered Morphine 4 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

At 11:36 AM, the nurse documented the patient was administered Morphine 4 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

At 1:55 PM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

At 8:24 PM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

At 10:12 PM, the nurse documented the patient was administered Morphine 4 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

Review of the PPN dated 1/6/24 revealed:

At 2:26 AM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

At 12:07 PM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

At 2:46 PM, the nurse documented the patient was administered Morphine 4 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

At 6:14 PM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

At 7:46 PM, the nurse documented the patient was administered Morphine 4 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

At 11:19 PM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

Review of the Physician's Orders dated 1/7/24 revealed an order for Toradol 30 mg IV every eight hours prn for pain.

Review of the PPN dated 1/7/24 revealed:

At 12:42 AM, the nurse documented the patient was administered Morphine 4 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

At 3:24 AM, the nurse documented the patient was administered Norco 5 mg/ 325 mg as needed for pain. There was no documentation of the location of the pain and pain severity. The nurse documented a pain reassessment of "effective" at 3:24 AM, the same time the Norco was administered.

At 10:47 AM, the nurse documented the patient was administered Toradol 30 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

At 1:09 PM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

At 5:44 PM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

At 9:11 PM, the nurse documented the patient was administered Toradol 30 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

Review of the PPN dated 1/8/24 revealed:

At 12:15 AM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

At 11:09 AM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

At 6:00 PM, the nurse documented the patient was administered Morphine 4 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

At 9:20 PM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

An interview was conducted on 1/11/24 at 2:59 PM with EI # 2, Case Management Director, who confirmed there was no documentation of a comprehensive pain assessment and/or reassessment for the above dates and times. EI # 2 confirmed a pain reassessment should not be performed at the same time of medication administration.

3. PI # 22 was admitted to the hospital on 12/19/23 with diagnoses including Ascites Secondary to Cirrhosis of the Liver, Symptomatic and Anasarca.

Review of the Physician Admission Orders dated 12/19/23 revealed an order for daily weights and Tylenol 650 mg every six hours prn headache or pain.

Review of the Physician's Orders dated 12/20/23 at 9:47 AM revealed an order to drain 6 liters of fluid post Paracentesis, then pull the drain.

Review of the Graphic Form dated 12/20/23 to 12/24/23 revealed a documented weight of 251 pounds on 12/20/23 and no documentation a weight was obtained on 12/21/23 through the discharge date of 12/24/23.

Review of the PPN dated 12/20/23 revealed the following:

At 10:15 AM, 1500 milliliters (ml) was drained from the "Paracentesis".
At 10:23 AM, 750 ml was drained from the "Paracentesis".
At 10:32 AM, 700 ml was drained from the "Paracentesis".
At 11:01 AM, 750 ml was drained from the "Paracentesis".
At 11:38 AM, 1000 ml was drained from the "Paracentesis".
At 11:55 AM, 700 ml was drained from the "Paracentesis" and the physician was contacted regarding the amount and color of the fluid. The physician verbalized to continue order to remove 6 liters.
At 12:44 PM, 200 ml was drained from the "Paracentesis" then the drain was removed from the right lower abdomen.

A total of 5600 ml of fluid was drained which was 400 ml less than the physician ordered 6 liters.

Further review of the PPN dated 12/20/23 revealed at 9:18 PM, the nurse documented the patient was administered Tylenol 650 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

Review of the Physician Progress Note dated 12/21/23 revealed the patient continued to have a "fluid wave" in the abdomen, decreased airflow with bibasilar rales and wheezing in the lungs, edema to the lower extremities, and the surgeon was to be reconsulted for a possible repeat paracentesis.

Review of the Physician Orders dated 12/21/23 revealed an order to transfuse 2 Units of PRBC (Packed Red Blood Cells).

Review of the PPN dated 12/21/23 revealed a blood transfusion of one unit of PRBC was started at 5:25 PM. Further review revealed the first vital signs (blood pressure, pulse, respirations, and temperature) was completed at 5:35 PM, which was 10 minutes after the transfusion was started. At 5:40 PM and 5:43 PM a temperature was documented. There was no documentation of the patient's blood pressure, pulse, and respirations. The nursing staff failed to perform vital signs every five minutes x 3 per the hospital policy.

Further review of the PPN dated 12/21/23 revealed at 6:35 PM, the nurse documented the patient was administered Tylenol 650 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

Review of the PPN dated 12/22/23 revealed at 12:39 AM, the nurse documented the patient was administered Tylenol 650 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

Review of the PPN dated 12/22/23 revealed at 5:46 AM, the nurse documented the patient was administered Tylenol 650 mg PRN for pain. There was no documentation of the location of the pain and pain severity.

An interview was conducted on 1/11/24 at 11:34 AM with EI # 2 who confirmed the staff failed to perform a comprehensive pain assessment and/or reassessment for the above dates and times, obtain daily weights as ordered, assess vital signs every five minutes x 3 per policy for blood administration, and failed to follow the physician's order to drain a total of 6 liters of fluid from a patient that had a Paracentesis.



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4. PI # 26 was admitted on 12/27/23 with Acute on Chronic Systolic Congestive Heart Failure.

Review of the MR revealed PI # 26 had a stage II pressure wound to the left buttock measuring 0.9 cm length (L) by 0.6 cm width (W) by 0.1 cm depth (D) and a stage II pressure wound to the right buttock measuring 2.0 cm L by 1.0 W by 0.1 D on admission.

Review of the PPNs from 12/28/23 to 1/6/24 revealed no documentation the wounds were measured and described. The facility failed to ensure the staff assessed wounds daily per policy.

Review of the physicians orders dated 12/29/23 revealed an order for Clonidine 0.1 mg PRN every four hours for systolic blood pressure greater than 170 or diastolic blood pressure greater than 105.

Review of Vital Sign Graph dated 12/31/23 revealed a blood pressure of 200/115 at 4:00 AM. Further review of the MR revealed no documentation Clonidine was administered as ordered by the physician.

An interview was conducted on 1/11/24 at 1:15 PM with EI # 7 who confirmed the staff failed to assess and document wounds per policy and failed to administer PRN medications per physician order for elevated blood pressure.

Based on review of medical records (MR), hospital policy and procedure and interviews with the staff it was determined the hospital failed to ensure a nursing care plan was developed and updated for each patient admitted to the hospital.

This did affect Patient Identifier (PI) # 17, PI # 18, PI # 21, three of four swing bed patients, PI # 28, and PI # 22, two of five inpatient MR's review requiring a surgical procedure, and had the potential to negatively affect all patients admitted to the hospital.

Findings include:

Hospital Policy: Assessment of Patients and Care Plans
Policy Number: Not documented
Revised Date: 9/23

...Text:

An RN (Registered Nurse) will assess the patient within the first four hours of admission...

Re-assessment will be done when the patient's condition changes or upon patient or family request, but at least once a shift...

The goals in the care plan will be based on the nursing assessment and be realistic, measurable, and consistent with the therapy prescribed by the physician, include the patient education needs identified in the assessment or re-assessment.

1. PI # 17 was admitted to the hospital swing bed unit on 1/6/24 with diagnoses including Cerebral Infarction/Multiple Brain Lesions with Hemorrhage into at Least One of these Lesions and Poor Balance with Diminished Mentation.

Review of the MR revealed no documentation a nursing care plan was developed on admission and updated as needed with changes in the patient's condition.

An interview was conducted on 1/11/24 at 9:18 AM with Employee Identifier (EI) # 2, Case Management Director, who confirmed the staff failed to complete a nursing care plan on PI # 17.

2. PI # 18 was admitted to the hospital swing bed unit on 1/9/24 with diagnoses including Pneumonia and Congestive Heart Failure.

Review of the MR revealed no documentation a nursing care plan was developed on admission and updated as needed with changes in the patient's condition.

An interview was conducted on 1/11/24 at 9:36 AM with EI # 2 who confirmed the staff failed to complete a nursing care plan on PI # 18.

3. PI # 21 was admitted to the hospital swing bed unit on 8/17/23 with a diagnosis of Right-sided CVA (Cerebral Vascular Accident).

Review of the MR revealed no documentation a nursing care plan was developed on admission and updated as needed with changes in the patient's condition.

An interview was conducted on 1/11/24 at 2:25 PM with EI # 2 who confirmed the staff failed to complete a nursing care plan on PI # 21.

4. PI # 28 was admitted to the hospital on 1/4/24 with a diagnosis of Cellulitis and Abscess of the Left Axilla Extending into the Left Chest Wall and Left Breast.

Review of the MR revealed PI # 28 required the administration of as needed pain medications once on 1/4/24, six times on 1/5/24, nine times on 1/6/24, seven times on 1/7/24, and eight times on 1/8/24.

Review of the Nursing Care Plan dated 1/11/24 revealed documentation of skin integrity-actual impairment as the problem. There was no documentation of a nursing care plan for pain interventions and goals.

An interview was conducted on 1/11/24 at 2:59 PM with EI # 2 who confirmed there was no documentation of a nursing pain intervention and goal on the nursing care plan for PI # 28.

5. PI # 22 was admitted to the hospital on 12/19/23 with diagnoses including Ascites Secondary to Cirrhosis of the Liver, Symptomatic and Anasarca.

Review of the Nursing Care Plan dated 1/11/24 revealed documentation of ineffective peripheral tissue perfusion related to decreased blood flow. Further review revealed no nursing interventions and goals for the problem of ineffective peripheral tissue perfusion related to decreased blood flow.

An interview was conducted on 1/11/24 at 11:34 AM with EI # 2 who confirmed there was no documentation of a nursing intervention and goals on the nursing care plan for PI # 22.

Based on observations during a tour of Senior Care Unit, facility policies, and interviews with staff, it was determined the facility failed to ensure all medications dispensed to patients were ordered by the physician.

This deficient practice affected one of ten patients in the Senior Care Unit including Patient Identifier (PI) # 2 and had the potential to affect all patients in this facility.

Findings include:

Facility Policy: Medication Samples
Policy Number: Not Documented
Revised Date: 12/21

Purpose: To establish guidelines for the use of samples.

Policy: Medication samples are prohibited on-site at Wiregrass Medical Center.

...2. If a physician has a request, the representative may order for the physician's personal use. These should never be left in the hospital department where the physician practices...

3. Physicians may supply patients with sample medications. These medications will be treated as any other patient's own medication.

Facility Policy: Use of Patient's Own Medication
Policy Number: Not Documented
Revised Date: 8/14/15

Purpose: To describe a method to safely manage medications brought into the hospital by patients and their families...

Patients may use their own medications under the following circumstances:

1. The medication is not on the hospital formulary...
2. A patient prefers to use their own medication rather than taking the hospital formulary substitute.
3. The medication must be verified by a pharmacist.

Facility Policy: Distribution of Medication in Wiregrass Hospital
Policy Number: Not Documented
Revised Date: 9/15

...Statement of Purpose: To establish a standard system for ordering and dispensing medications to patients...

II. Dispensing/Charging

A. Medications are dispensed from Pyxis machines...

III. Patient Profiles...

B. All medications ordered for the patient are to be listed on the profile. No med should be dispensed without an order...

1. A tour of the Senior Care Unit medication room was conducted on 1/9/24 at 11:00 AM with Employee Identifier (EI) # 3, Chief Nursing Officer.

In the medicine cart drawer for PI # 2 was a physician's sample package of Rexulti 2 mg (milligram) tablets. There was no patient label on the package.

Review of the physician's orders revealed no documentation of an order for Rexulti.

Review of the MAR (Medication Administration Record) dated 1/9/24 revealed no documentation of the Rexulti medication.

During the tour, EI # 3 confirmed the sample medication Rexulti was for PI # 2 and there was no physician order for the medication.

An interview was conducted on 1/10/24 at 9:32 AM with EI # 10, Pharmacist, who stated the sample medications were treated as the use of the patient's own medications and sample medications were to have a label printed on them and placed in the patient's drawer on the medication cart.

Based on observation, hospital policies and procedures, Centers for Disease Control and Prevention (CDC) Injection Safety, and interview, it was determined the hospital failed to ensure:

a. Expired supplies, medications and solutions were not available for patient use.

b. Opened multi-dose medication vials were not stored in the anesthesia cart.

This deficient practice had the potential to affect all patients receiving care at this hospital.

Findings include:

Hospital Policy: Anesthesia Rules and Regulations
Policy Number: Not Documented
Revised: 1/14

Procedures:

To maintain ...safety and effective anesthesia care of the patient ...

...All medicines opened and unused are discarded at the completion of the case.

CDC Injection Safety
Reviewed: 6/20/19

Questions about Multi-dose Vials

If a multi-dose vial enters an immediate patient treatment area, it should be dedicated for single patient use only.

Example of immediate patient treatment areas include ...anesthesia and procedure carts ...

If a ...vial has not been opened or accessed (needle punctured), it should be discarded according to manufacturer's expiration date.

The manufacturer's expiration date refers to the date after which an unopened...vial should not be used.

Facility Policy: Distribution of Medication in Wiregrass Hospital
Policy Number: not documented
Revised/Reviewed Date: 9/15

...Purpose: To establish a standard system for ordering and dispensing medications...

IV. Stock Medications:

...C. Monthly checks will be done by Pharmacy for expiration dates...

1. During a tour of the Outpatient Surgery unit on 1/9/24 at 11:10 AM, with Employee Identifier (EI) # 8, Certified Registered Nurse Anesthetist (CRNA), the following medications were observed and available for patient use:

a. One opened multi-dose vial Neostigmine Methyl Sulfate Injection 10 milligram (mg) per 10 milliliters (ml) in the Operating Room (OR) anesthesia cart.

b. Five Hydro Morphine Carpuject syringes 2 mg/ml in the narcotic cabinet expired 10/31/23.

c. Seven Cisatracurium vials 2 mg/ml in the OR Supply Room refrigerator expired 7/31/23.

An interview was conducted during the tour with EI # 8, who confirmed the above medication vials were opened, expired and available for patient use.

2. During a tour of the Intensive Care Unit (ICU) medication storage room on 1/9/24 at 1:05 PM the following out of date intravenous (IV) supplies were observed:

a. Four D5 0.9% NS (Dextrose 5 %, Normal Saline 0.9 %) 500 ml bags with an expiration date of 10/23.
b. One D5NS 500 ml bag with an expiration date of 11/22.
c. Five D5NS 1000 ml bags with an expiration date of 11/23.
d. One 1/2 NS 1000 ml bag with an expiration date of 10/23.
e. Two D5W (Dextrose 5 % in Water) 50 ml bags with an expiration date of 10/23.
f. Three NS 25 ml bags with an expiration date of 11/23.
g. Two NS 50 ml bags with an expiration date of 11/23.
h. Three NS 100 ml bags with an expiration date of 11/23.
i. Two D5W 50 ml bags with an expiration date of 10/23.
j. Four Plasma-Lyte 7.4 pH (percent of hydrogen) 1000 ml bags with an expiration date of 11/23.
k. Three Plasma-Lyte 7.4 pH 500 ml bags with an expiration date of 10/23.

During the tour EI # 3, Chief Nursing Officer, confirmed the IV medications were expired and available for patient use.

3. During a tour of the Medical Surgical Unit medication storage room on 1/9/24 at 1:30 PM, the following expired IV medications were observed:

a. Seven D5W 100 ml bags with an expiration date of 11/23.
b. Thirteen D5W 50 ml bags with an expiration date of 11/23.
c. Nine D5W 1000 ml bags with an expiration date of 11/23.
d. Four D10W 1000 ml bags with an expiration date of 11/23.
e. Three Plasma- Lyte 500 ml bags with and expiration date of 10/23.
f. One Sodium chloride 500 ml bag with an expiration date of 10/23.
g. Three 5% Dextrose and 0.9% Sodium Chloride 500 ml bags with an expiration date of 10/23.
h. One 5% Dextrose 1000 ml bag with an expiration date of 2/23.

During the tour EI # 3 confirmed the IV medications were expired and available for patient use.

4. A tour of the Emergency Room on 1/10/24 at 9:59 AM revealed the following expired medications and supplies in the crash cart located in the trauma room.

a. Lidocaine 2 grams 500 ml vial expired 11/23

b. Angiocath 16 gauge needles two expired 9/23.

c. Angiocath 16 gauge needle one expired 9/23.

An interview was conducted on 1/10/24 at 10:15 AM with EI # 6, Quality Director, who confirmed the expired medication and supplies were available for patient use.




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Based on review of the hospital policies, dietary consultant agreement, hospital diet manual, observations, and interviews, it was determined the hospital failed to ensure:

1. The kitchen was maintained in a clean, safe, sanitary manner and free of rodents.

2. Dietary Services were incorporated into the hospital Quality Assessment and Performance Improvement (QAPI) program.

3. A Registered Dietitian was available to supervise the nutritional aspects of patient care.

4. Diet menus were available to meet the needs of patients requiring special diets.

5. The dietary manual was reviewed by the medical staff and a Registered Dietitian.

This did affect Patient Identifier (PI) # 10 and had the potential to negatively affect all patients served by the facility.

Findings:

Refer to tags A 0620, A 0621, A 0629, and A 0631.

Based on observations, review of hospital policies and interviews it was determined the Food Services Director failed to ensure:

1. The kitchen was maintained in a clean, safe, sanitary manner and free of rodents.

2. Dietary Services were incorporated into the hospital Quality Assessment and Performance Improvement (QAPI) program.

This had the potential to affect all persons served by the hospital.

Findings include:

Hospital Policy: Pest Control
Policy Number: 032
Revision Date: 5/14

Policy statement: It is the center policy that there is a program established for the control of... rodents for the dining services department.

Action Steps: ...The food services director coordinates with the Director of Maintenance to arrange pest control services on a monthly basis, or as needed.

Hospital Policy: Equipment
Policy Number: 030
Revision Date: 5/14

Policy statement: It is the center policy that all Food service equipment is clean, sanitary, and in proper working order.

Action Steps:

1. The Food Services Director will ensure that all equipment is routinely cleaned and maintained...

3. The Food Services Director ensures that all food contact equipment is cleaned and sanitized after every use...

Hospital Policy: Environment
Policy Number: 031
Revision Date: 5/14

Policy: It is the center policy that all food preparation areas, food service areas...will be maintained in a clean and sanitary condition.

Action Steps:

1. The Food Services Director will ensure that the physical plant is maintained in a clean and sanitary manner, including the floors...

3. The Food Services Director will ensure that all food contact surfaces are cleaned and sanitized after each use.

Hospital Policy: QAPI
Policy Number: 036
Revision Date: 5/14

Policy statement: It is the center policy that dining services department will participate in a QAPI process that includes safety, customer satisfaction, food services operations, clinical care, and regulatory compliance with all applicable local, state, and federal statutes.

Action Steps:

1. The Food Services Director will conduct customer satisfaction surveys with residents/patients at a minimum of four times per year. The survey will include, but not limited to, the following:

a. Staff responsiveness.

b. Menu variety.

c. Food quality - taste, temperature, appearance.

d. Timeliness of service.

e. Cleanliness of environment.

2. The Food Services Director will conduct routine quality audits of the meal service delivery practices, including proper food storage, preparation, and service.

3. The Registered Dietitian will conduct clinical care delivery audits as appropriate.

4. Results of the clinical and operations audits, and customer satisfaction surveys, will be analyzed. Opportunities for process improvement will be identified.

5. An action plan, including appropriate monitoring, will be implemented.

6. Quality improvement plans, including monitoring, will be implemented.

7. The results of the QAPI process will be reported to the center Quality Assurance Committee.

1. A tour of the dietary department was conducted on 1/9/24 at 10:33 AM with Employee Identifier (EI) # 11, Dietary Account Manager (Food Services Director). The following observations were made:

An 8-pound opened container of Strawberry Glaze was observed in the Dry Storage Area with a use by date of 10/31/23.

The grease in the two kitchen fryers had a layer of a brown substance, with the appearance of corn mill grounds, over the surface of the grease.

The sides, front, and back splash of both fryers and oven had brown grease build up.

The sides of the gas stove range had brown grease build up.

The floor around and under the fryers had brown grease build up.

A stack of eight oven sheet pans had brown and black grime on all side of the sheet pans.

Two roast pans had brown grime on the bottoms of the pans.

The "tea and juice counter" had dark brown grime under the counter.

Rodent droppings were observed under the food preparation /chopping counter, beside the tip skillet, and under the dessert counter, garbage disposal, food service line and dishwasher.

An interview was conducted during the tour with EI # 11, who confirmed the opened container of strawberry glaze was beyond the use by date, the brown and black grime on the sheet pans and roast pan, the brown grime under the tea and juice counter, and the buildup of grease on the fryers, gas stove range, and oven. EI # 11 also confirmed the droppings found in the kitchen were from a rodent and stated she/he has seen rodents "every day when you turn on the light" since she/he began the position in May 23. EI # 11 further verbalized she/he had reported the rodent issue to maintenance several times.

An interview was conducted on 1/11/24 at 3:55 PM with EI # 14, Maintenance Director. EI # 14 verbalized he/she had not been aware of the rodent issue in the dietary department and confirmed there was no documentation of a work order for the rodent issue in the dietary department.

2. An interview was conducted on 1/9/24 at 1:30 PM with EI # 11. EI # 11 was asked what quality indicators were being monitored and reported to the hospital QAPI committee. EI # 11 verbalized there were no quality indicators for the dietary department and the dietary department did not participate in the hospital QAPI.

During the interview, EI # 11 walked toward the dishwashing area followed by the surveyor. EI # 11 came to a sudden stop and jumped back with the appearance of being startled by something in the dishwashing area. EI # 11 verbalized he/she had observed a rodent in the dishwashing area approximately three inches in circular width.

EI # 11 then directed the surveyor to two wooden boxes with circles approximately one to two inches in width and length in the dishwashing area and three silver rectangular boxes located in the kitchen area all used for rodent pest control.

An interview was conducted on 1/9/24 at 1:50 PM with EI # 6, Quality Director, who confirmed there was no documentation of QAPI data for 2023 or 2024 for the dietary department and the dietary department did not participate in the QAPI program.

3. On 1/16/24 at 2:52 PM, EI # 3, Chief Nursing Officer, provided the hospital pest control invoices for 2023 to the surveyor via email.

Review of the hospital pest control invoices for 2023 revealed the hospital was provided rodent control pest service monthly.

Further review revealed documentation of the following number of rodent bait stations used for rodent pest control measures: "15" bait stations on 2/7/23, "17" bait stations on 3/20/23, and "13 bait stations" used since 4/14/23.

The same pest control measures were used with continued evidence of rodents in the dietary department.

Based on review of hospital policies, dietary consultant agreement provided by the facility, and interviews with staff, it was determined the hospital failed to ensure a dietitian was available to supervise the nutritional aspects of patient care to include:

1. Approving patient menus and nutritional supplements.

2. Patient, family, and caretaker dietary counseling.

3. Performing and documenting nutritional assessments and evaluating patient tolerance to therapeutic diets when appropriate.

4. Collaborating with other hospital services to plan and implement the nutritional needs of the patients.

5. Maintaining pertinent patient data necessary to recommend, prescribe, or modify therapeutic diets as needed to meet the nutritional needs of the patients.

This had the potential to negatively affect all patients requiring a dietary consult served by the hospital.

Findings include:

Hospital Policy: Nutritional Screening
Policy Number: Not documented
Revised Date: 6/22

...Statement of Purpose: To assign level of care based on degree of nutritional risk.

1. A preliminary screen is conducted on all patients. The preliminary screen is based on admitting diagnosis, patient diet orders and other information gathered through the admitting process.

2. Preliminary Screens: ...criteria will be used to trigger a dietary consult.

Hospital Policy: Professional Staffing
Policy Number: 001
Revised Date: 5/14

Policy Statement: It is the center policy that the dining services department operates under the direction of a qualified dietitian.

...Action Steps:

1... the center will employ a Registered Dietitian (RD)...

2. The RD is responsible for ensuring that all food service operations and practices meet current standards of practice and all regulatory requirements...

Hospital Policy: Menus
Policy Number: 004
Revised Date: 5/14

...Action Steps:

...5. The RD reviews and approves the menus. The RD will adjust the meal and/or menu plan to meet the individual needs as necessary, including cultural, religious, or ethnic preferences as appropriate...

During a tour of the Dietary Department on 1/9/24 at 1:30 PM, Employee Identifier (EI) # 11, Dietary Account Manager, was asked about the supervision and direction by an RD for the dietary department and patient menus. EI # 11 verbalized, she/he has not seen or spoken with the RD since starting her/his position in May 23. When the surveyor asked about setting up an interview with the RD, EI # 11 stated, "I'll see if the nursing home side can get in contact with (her/him). I've never talked to (her/him)" EI # 11 confirmed not having contact information for the RD.

Review of the Dietary Consultant Agreement provided by the hospital dated 2/24/2020 revealed documentation the agreement was for the nursing home. There was no documentation an RD was contracted or on staff to provide RD services for the hospital.

An interview was conducted with EI # 13, RD on 1/10/24 at 3:49 PM, EI # 13 was asked about providing supervision and direction to the hospital dietary department. EI # 13 stated, "If they have questions, they can ask but other than that I let them do their thing." EI # 13 confirmed he/she had not provided supervision and direction for the dietary department patient menu planning or therapeutic diets. EI # 13 confirmed, if the hospital had a consult for an RD, they would call but it doesn't happen often and stated, "I might get one phone call a year." EI # 13 confirmed the only time spent at the hospital would be for a consult if called.

Based on review the hospital policy, observation, and interviews with staff, it was determined the hospital failed to ensure patient menus met the needs of the patients.

This did affect Patient Identifier (PI) # 10, one of one patient with a physician ordered 1800 calorie ADA (American Diabetic Association) diet and had the potential to negatively affect all patients served by the hospital.

Findings include:

Hospital Policy: Menus
Policy Number: 004
Revised Date: 5/14

...Action Steps:

...5. The RD reviews and approves the menus. The RD will adjust the meal and/or menu plan to meet the individual needs as necessary, including cultural, religious, or ethnic preferences as appropriate...

1. PI # 10 was admitted to the hospital on 1/4/24 with diagnoses including Pneumonia, Hyperglycemia, and Confusion.

Review of the patient diet orders for 1/9/24 revealed documentation an 1800 calorie ADA diet was ordered for PI # 10.

An observation of plating the patient lunches was conducted on 1/9/24 at 11:18 AM. During the observation the following foods and amounts were provided for PI # 10 as well as for patients ordered a 2000 calorie ADA diet:

One slice of bread, one slice of turkey with gravy, four ounces (oz) of mash potatoes, 4 oz of Brussels sprouts and a prefilled cup with approximately 4 oz of pears.

There was no distinguishing difference in the food or amounts of food provided to PI # 10 with an 1800 calorie ADA diet and others with a 2000 calorie ADA diet.

Review of the 23-24 Diet Guide Sheet revealed no documentation of a 1800 ADA diet for the dietary meal plan.

An interview was conducted on 1/9/24 at 1:30 PM with Employee Identifier (EI) # 11, Dietary Account Manager, who was asked how the dietary staff determined the food and food measurement amounts between the 1800 ADA and the 2000 ADA diet. EI # 11 stated, "we don't know, we don't have a printout for the hospital side..."

An interview was conducted with EI # 13, RD on 1/10/23 at 3:49 PM, EI # 13 confirmed he/she had not provided supervision and direction for the dietary department patient menu planning or therapeutic diets.

Based on review of hospital diet manual and staff interview, it was determined the facility failed to ensure the dietary manual was reviewed by the medical staff and a Registered Dietician (RD).

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

Findings include:

During a tour of the Dietary Department on 1/9/24 at 1:30 PM with Employee Identifier (EI) # 11, Dietary Account Manager, the surveyor requested the therapeutic diet manual. Review of the hospital diet manual 2019 Edition, revealed documentation the manual had been reviewed and approved by the Director of Nursing on 2/6/23. There was no documentation the hospital diet manual was reviewed and approved by the medical staff and RD.

An interview was conducted during the tour with EI # 11, who confirmed there was no documentation the hospital diet manual was reviewed and approved by the medical staff and RD.

A second interview was conducted with EI # 13, RD on 1/10/23 at 3:49 PM, who confirmed no documentation the hospital diet manual was reviewed and approved by the medical staff and RD.

Based on observations, review of hospital policies and interviews it was determined the hospital failed to ensure the facility was clean, safe, sanitary, and free of rodents.

This had the potential to affect all persons served by the hospital.

Findings include:

Refer to tag A 0701.

Based on observations, review of hospital policies and interviews it was determined the hospital failed to ensure the facility was maintained in a clean, safe, sanitary manner and free of rodents.

This had the potential to affect all persons served by the hospital.

Findings include:

Hospital Policy: Pest Control
Policy Number: 032
Revision Date: 5/14

Policy statement: It is the center policy that there is a program established for the control of... rodents for the dining services department.

Action Steps: ...The food services director coordinates with the Director of Maintenance to arrange pest control services on a monthly basis, or as needed.

Hospital Policy: Equipment
Policy Number: 030
Revision Date: 5/14

Policy statement: It is the center policy that all Food service equipment is clean, sanitary, and in proper working order.

Action Steps:

1. The Food Services Director will ensure that all equipment is routinely cleaned and maintained...

3. The Food Services Director ensures that all food contact equipment is cleaned and sanitized after every use...

Hospital Policy: Environment
Policy Number: 031
Revision Date: 5/14

Policy: It is the center policy that all food preparation areas, food service areas...will be maintained in a clean and sanitary condition.

Action Steps:

1. The Food Services Director will ensure that the physical plant is maintained in a clean and sanitary manner, including the floors...

3. The Food Services Director will ensure that all food contact surfaces are cleaned and sanitized after each use.

1. During a tour of the Senior Care Unit conducted on 1/9/24 at 10:30 AM with Employee Identifier (EI) # 3, Chief Nursing Officer, the following items in need of repair were identified:

a. In room 403 the wall material was loose, cracked and could be easily pushed in with the hand. The Baseboards were loose and peeling away from the wall.

b. In room 404 an area of paint had peeled from wall measuring approximately 6 inches by 15 inches.

c. In room 405 the wall material under the air conditioner unit was loose and could be easily pushed in with the hand. The baseboards were peeling from the wall.

During the tour, EI # 3 confirmed the unit had not been maintained to ensure the safety and well being of the patients.

2. A tour of the dietary department was conducted on 1/9/24 at 10:33 AM with EI # 11, Dietary Account Manager (Food Services Director). The following observations were made:

The grease in the two kitchen fryers had a layer of a brown substance, with the appearance of corn mill grounds, over the surface of the grease.

The sides, front, and back splash of both fryers and oven had brown grease build up.

The sides of the gas stove range had brown grease build up.

The floor around and under the fryers had brown grease build up.

The "tea and juice counter" had dark brown grime under the counter.

Rodent droppings were observed under the food preparation /chopping counter, beside the tip skillet, and under the dessert counter, garbage disposal, food service line and dishwasher.

An interview was conducted during the tour with EI # 11, who confirmed there was brown grime under the tea and juice counter, and grease buildup on the fryers, gas stove range, and oven. EI # 11 also confirmed the droppings observed in the kitchen were from rodents.

An interview was conducted on 1/11/24 at 3:55 PM with EI # 14, Maintenance Director. EI # 14 verbalized he/she had not been aware of the rodent issue in the dietary department and confirmed there was no documentation of a work order for the rodent issue in the dietary department.

A second interview was conducted on 1/9/24 at 1:30 PM with EI # 11. During the interview, EI # 11 walked toward the dishwashing area followed by the surveyor. EI # 11 came to a sudden stop and jumped back with the appearance of being startled by something in the dishwashing area. EI # 11 verbalized he/she had observed a rodent in the dishwashing area approximately three inches in circular width.

EI # 11 then directed the surveyor to two wooden boxes with circles approximately one to two inches in width and length in the dishwashing area and three silver rectangular boxes located in the kitchen area all used for rodent pest control.

3. Review of the hospital pest control service invoices for 2023 revealed the hospital was provided rodent pest control service monthly.

Further review revealed documentation of the following number of rodent bait stations used for rodent pest control measures: "15" bait stations on 2/7/23, "17" bait stations on 3/20/23, and "13 bait stations" used monthly since 4/14/23.

The same pest control measures were used with continued evidence of rodents in the dietary department.

Based on observations, facility policy and procedure, Clorox disinfect wipe manufacturers instructions, Centers for Disease Control and Prevention (CDC) Best Practices for Environmental Cleaning in Healthcare Facilities, and interviews, it was determined the facility failed to ensure the staff:

1. Wore gloves when administering intravenous (IV) medications and blood products.

2. Performed hand hygiene per the facility policy.

3. Cleaned and disinfected reusable patient equipment per manufacturers instructions and CDC best practices.

This deficient practice did affect Unsampled Patient # 1, Unsampled Patient # 2, Unsampled Patient # 3, and had the potential to negatively affect all patients admitted to this hospital.

Findings include:

Facility Policy: Hand Hygiene-CDC (Centers for Disease Control and Prevention) Guidelines
Policy Number: not documented
Revised Date: 9/19/23

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

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

Before each patient encounter...
Before applying gloves...
After coming in contact with the patient's intact skin...
After contact with medical equipment/supplies in patient areas
Always after removing gloves...

Procedure:

Using antimicrobial soap and water or non-antimicrobial soap and water:

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

Notes:
...Always follow Standard Precautions...
Gloves are to be worn when in contact with blood, bodily fluids, mucous membranes, dressings, non intact skin...is anticipated...

Clorox Disinfectant Wipes Manufacturers Instructions
Copyright Date: 2016

...Disinfection...

To clean and disinfect...wipe surface to be disinfected. Use enough wipes for treated surface to remain visibly wet...let air dry.

CDC Best Practices for Environmental Cleaning in Healthcare Facilities
Reviewed Date: 4/21/2020

...4. Environmental Cleaning Procedures...

4.7 Noncritical patient care equipment

...noncritical patient care equipment includes...stethoscopes. These high-touch items are: used by healthcare workers to touch patients (i.e. stethoscopes)...often shared between patients.

...Table 26: Recommended Selection and Care of Noncritical Patient Care Equipment.

...Shared...Frequency...Before and after each use..clean and disinfect...

1. An observation of terminal cleaning was conducted on 1/9/24 at 1:10 PM with EI # 16, Environmental Services. EI # 16 changed gloves 13 times without performing hand hygiene after glove removal and prior to donning clean gloves.

An interview conducted on 1/11/24 at 12:50 PM with EI # 13, Infection Preventionist, confirmed the staff failed to follow hospital policy for hand hygiene after glove removal.

2. An observation of IV medication administration was conducted on 1/9/24 at 2:30 PM for unsampled patient # 1 in room 609.

Employee Identifier (EI) # 23, Registered Nurse (RN), performed hand hygiene with soap and water, donned gloves, and opened the IV tubing package. EI # 23 stated he/she had the wrong tubing, removed gloves, performed hand hygiene and left the patient room.

Upon returning to the room, EI # 23 performed hand hygiene, connected the new tubing to the IV bag, prepped the Heparin Lock device on the patient's right arm, and connected the IV. EI # 23 failed to follow aseptic technique and apply gloves before administering the IV medication.

EI # 23 then donned glove and prepared to assist with changing the patient's sheets. EI # 23 failed to perform hand hygiene prior to donning gloves.

In an interview conducted on 1/11/24 at 12:50 PM with EI # 13, Infection Preventionist, EI # 13 confirmed the staff failed to follow hospital policy and aseptic technique when administering the IV medications and donning gloves.

3. An observation was conducted on 1/9/24 to observe a laboratory (lab) blood collection procedure with EI # 17, Lab Assistant, EI # 18, Lab Assistant, and EI # 19, Registered Nurse for Unsampled Patient # 2.

At 3:55 PM, EI # 17, wheeled the patient to the outpatient lab room, gathered supplies, then donned gloves without hand hygiene.

After puncture site was cleansed with alcohol, EI # 17 then palpated the site with gloved hand and proceeded to insert a needle. EI # 17 failed to re-cleanse the palpated vein puncture site prior to puncturing with a needle.

After the unsuccessful venipuncture attempt, EI # 17 removed gloves, used telephone in the lab room to call for assistance then documented on the medical record. EI # 17 failed to perform hand hygiene after removing gloves.

At 4:10 PM, EI # 18 entered the outpatient lab room, donned gloves, and applied tourniquet to the patient's right arm. EI # 18 failed to perform hand hygiene prior to donning gloves.

After EI # 18 was unsuccessful in palpating a vein, EI # 18 removed gloves, obtained clean syringes, and donned gloves without hand hygiene. EI # 18 failed to perform hand hygiene after removing gloves and prior to donning gloves.

At 4:17 PM, EI # 19 entered the outpatient lab room.

After obtaining and opening sterile supplies with gloved hands, EI # 19 assisted the patient with the placement of the patient's shirt to give access to infusaport (Implantable Central Venous Access Device). EI # 19 then proceeded to remove Huber needle from paper sleeve, attach normal saline flush, open and don sterile gloves. EI # 19 failed to remove gloves and perform hand hygiene after assisting with the patient's shirt and prior to connecting the normal saline to the sterile Huber needle and donning sterile gloves.

After the infusaport was accessed and flushed, EI # 19 removed gloves and donned sterile gloves to apply the sterile gauze and transparent dressing to the infusaport access site. EI # 19 failed to perform hand hygiene after glove removal and before donning sterile gloves.

An interview was conducted on 1/10/24 at 9:01 AM with EI # 22, Lab Director, who confirmed EI # 17, EI # 18, and EI # 19 failed to perform hand hygiene per the hospital policy.

4. An observation of IV medication administration was conducted on 1/10/24 at 9:30 AM on an unsampled patient # 3 in room 514.

EI # 24, RN, performed hand hygiene, prepped the IV tubing port, connected the syringe containing Protonix 40 mg and administered the medication. EI # 24 failed to follow aseptic technique and apply gloves before administering the IV medication.

In an interview conducted on 1/11/24 at 12:50 PM with EI # 13, Infection Preventionist, EI # 13 confirmed the staff failed to follow hospital policy and aseptic technique when administering the IV medications and donning gloves.

5. An observation was conducted on 1/10/24 at 9:41 AM to observe blood administration with EI # 20, Registered Nurse for Unsampled Patient # 2.

EI # 20 performed hand hygiene using soap and water, used bare hand to turn the sink faucet off, then used contaminated bare hand to cleanse the hub site of the infusaport access line, connect a normal saline flush to the access line, aspirate blood return of the infusaport then flush the infusaport access line with normal saline.

EI # 20 obtained Clorox disinfectant wipe, cleaned bedside table, then immediately placed IV 500 ml bag of 0.9 % Sodium Chloride and infusion set tubing on bedside table without allowing table to air dry. EI # 20 then proceeded to hang the IV Sodium Chloride bag on the IV pole, open and connect IV infusion set tubing to Sodium Chloride IV bag, prime IV tubing with Sodium Chloride, and connect the IV tubing to the patient infusaport access line without performing hand hygiene after disinfecting bedside table and applying gloves.

At 9:41 AM, EI # 20 walked to the blood bank to obtain blood. After entering the blood bank, EI # 20 donned gloves without hand hygiene then removed his/her gloves and exited the blood bank without performing hand hygiene.

At 9:47 AM, EI # 20 returned to the blood bank with patient paperwork and donned gloves without hand hygiene.

After EI # 20 verified the blood with EI # 21, Medical Lab Technician, EI # 21 removed his/her gloves and without performing hand hygiene, exited the blood bank and entered the lab area to obtain paperwork.

EI # 20 exited the blood bank with gloves on, waited for EI # 21 to make copy of the patient's paperwork, returned to the patient area, stopped IV pump, then verified the blood unit with another nurse. After the blood unit was verified, EI # 20 hung the IV blood unit on the IV pole and a hole was observed in the right glove at the tip of the thumb exposing EI # 20's fingernail. EI # 20 then continued to use the same gloves with the hole in the right thumb to prime the blood through the tubing, connect the blood to the IV pump, disinfect infusaport access line hub with alcohol, connect IV tubing to the access line hub, and start the blood infusion.

EI # 20 removed gloves, removed stethoscope from around his/her neck, listened to the patient's chest, and returned the uncleaned stethoscope to his/her neck.

EI # 20 then performed hand hygiene using soap and water then used bare hand to turn sink faucet off.

EI # 20 removed stethoscope from around his/her neck, listened to the patient's chest, and returned the uncleaned stethoscope to his/her neck two additional times.

After the blood was administered, EI # 20 performed hand hygiene using soap and water four times then used bare hand to turn sink faucet off each time hand hygiene was performed.

EI # 20 failed to clean the stethoscope before and after each use.

An interview was conducted on 1/11/24 at 4:16 PM with EI # 2, Case Management Director, who confirmed EI # 20 failed to use gloves and perform hand hygiene per the hospital policy. EI # 20 also confirmed the stethoscope was not cleaned per CDC best practices.



40119




49797

Based on observation, hospital policy and procedure, and interview, it was determined the hospital failed to ensure a medical history and physical (H&P) examination was completed and documented prior to an invasive procedure.

This affected one of five outpatient surgical medical records (MR) reviewed including Patient Identifier (PI) # 44, and had the potential to affect all patients served at this hospital.

Findings include:

Hospital Policy: Content and Timeliness of Completed Patient Record
Policy Number: None Documented
Date Revised: 2023

Purpose:

To ensure timely completion of medical records by physicians...

...A history and physical is required to be completed within 24 hours of admission or prior to an invasive procedure.

1. PI # 44 was admitted on 12/8/23 with chief complaint including Crohns Disease.

Review of the medical record revealed Patient Identifier (PI) # 44 had a Colonoscopy Possible Biopsy and or Polypectomy procedure performed on 12/8/23.

Further Review of PI # 44's medical record revealed no documentation of a H&P prior to the invasive procedure.

An interview was conducted on 1/10/24 at 3:39 PM with Employee Identifier (EI) # 9, Medical Record Supervisor, who verified no documentation of a H&P was completed prior to the invasive procedure per the hospital's policy.

Based on review of Medical Records (MR), hospital policy, and interview, it was determined the hospital failed to ensure a pre-anesthesia evaluation was completed and documented by an individual qualified to administer anesthesia, within 48 hours prior to surgery or a procedure requiring anesthesia services.

This affected one of five inpatient surgical MR's reviewed including Patient Identifier (PI) # 28 and had the potential to affect all patients requiring surgical services the hospital.

Findings include:

Hospital Policy: Rules and Regulations
Policy Number: None documented
Date Revised: 1/14

... Preanesthetic Care: ...The anesthetist must perform a preoperative evaluation of patients scheduled for surgery. This includes a review of that patient's chart including consultations, history and physical, lab (laboratory), EKG (Electrocardiogram), and radiology and to determine the physical status of the patient...

1. PI # 28 was admitted to the hospital on 1/4/24 with a diagnosis of Cellulitis and Abscess of the Left Axilla Extending into the Left Chest Wall and Left Breast.

Review of the Operative Note dated 1/8/24 revealed the patient underwent a packing removal under sedation with IV (intravenous) anesthesia administered.

Review of the MR revealed no documentation of a preoperative anesthesia evaluation within 48 hours of the packing removal operative procedure.

An interview was conducted on 1/11/24 at 2:59 PM with Employee Identifier (EI) # 2, Case Management Director, who confirmed there was no documentation of a preoperative anesthesia evaluation within 48 hours of the packing removal operative procedure.