HospitalInspections.org

Based on a review of 18 personnel files and staff interviews, it was determined the hospital failed:

1. To assure 3 of 7 employees who were required to have Cardiopulmonary Resuscitation (CPR) had current CPR certifications.

2. To assure 6 of 7 employees reviewed were competent to complete duties assigned to them.

Findings include:

Review of the personnel files on 2/3/11 revealed 1 of 1 licensed practical nurse (LPN), 1 of 6 registered nurses (RN) and 1 of 1 licensed physical therapy assistant (LPTA) did not have current CPR.

Review of the personnel files for competencies revealed no documentation of competencies for 1 of 1 LPN, 4 of 6 RN's and 1 of 1 LPTA reviewed.

During an interview on 2/3/11 at 3:00 PM, Employee Identifier (EI) # 1, the Director of Nurses/Assistant Administrator, was unable to provide documentation of the current CPR's and competencies for the aforementioned staff members. At the exit conference EI #1 stated that they would continue to look for documentation of the CPR and competencies.

Based on observations and interviews with administrative staff, it was determined the hospital failed to post instructions informing patients of their right to file a grievance with the State agency. Also, this information was not included in the paperwork provided to the patients upon admission. This had the potential to affect all patients receiving services from the hospital.

Findings include:

1. During a tour of the Emergency Department (ED) on 2/1/11 at 12:45 P.M. with the Director of Nursing/Assistant Administrator, Employee Identifier (EI) #1, it was noted the hospital did not have the toll free State Hot Line number posted for patients to voice grievances.

Review of the Patient Rights section of the admission paperwork revealed no documentation of the State Hot Line number.

Upon observation on 2/3/11 at 10:00 A.M. it was noted the number still was not posted in the ED waiting area.

An interview with EI #1 on 2/3/11 at 3:00 P.M. confirmed the State Hot Line phone was not posted in the Emergency Department or the Outpatient Waiting area.

Based on medical record review and interviews with administrative staff, the hospital failed to assure there were physician's orders for the use of restraints. This affected 2 of 3 records reviewed with restraints and had the potential to affect all patients serviced by the hospital.

1. Medical Record #12 was admitted to the hospital 12/28/10 with Pneumonia.

Review of the Patient Progress Note dated 1/4/11 revealed documentation by the Skilled Nurse(SN) at 2000 as follows: "...soft wrist restraints on bil(bilaterally), released x 15 min(minutes) circulation checks WNL(within normal limits)." On 1/5/11 at 0200 the SN documented "...loosened bil wrist restraints x 15 min, massaged wrists." Also, on 1/5/11 at 1845 the SN documented "soft restraints intact." and at 2000 "wrist restraints removed."

There were no Physician's orders in the medical record for the restraints.

In an interview with the Director of Nursing/Assistant Administrator, Employee Identifier (EI) #1, on 2/3/11 at 2:00 P.M. it was confirmed there were no orders for restraints for this patient.




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2. MR # 16 was admitted to the hospital 1/20/11 at 1149 with diagnoses including Altered Level Of Conciousness and Respiratory Distress (possible aspiration).

Review of the Physical Restraint Flow sheet dated 1/20/11 at "8 PM" revealed documentation by EI # 5, Licensed Practical Nurse (LPN), the patient had bilateral soft restraints to the upper extremities. Review of the Physician's order dated 1/20/11 revealed a verbal order for soft wrist restraints at 2200 which was 2 hours after restraints were applied.

In an interview with EI #1, on 2/3/11 at 2:35 P.M. it was confirmed there was no order for restraints for this patient before they were applied.

Based on medical record (MR) review and an interview with administrative staff, it was determined the hospital failed to assure orders for the use of restraints were not written on an as needed basis. This affected 1 of 3 records reviewed with restraints. This affected MR # 9 and had the potential to affect all patients with restraints.

Findings include:

MR # 9 was admitted to the hospital on 1/9/11 with the diagnoses of Urinary Tract Infection and Dehydration.

Review of the Physician's orders revealed the Physician's order dated 1/9/11, "May use soft wrist restraints".

Review of the Patient Progress Notes revealed the staff continued to apply the soft wrist restraints from 1/10/11 through 1/14/11 with no restraint orders except for the 1/9/11 order.

Review of the Patient Progress Notes revealed the following restraint documentation:
1. 1/10/11 at 2230 "....Soft Wrist restraints intact..."
2. 1/11/11 at 0400 "....Soft wrist restraints intact..."
3. 1/11/11 at 0815 "....Light wrist restraints for pt (patient) safety..."
4. 1/11/11 at 2000 "....wrist restraints loosened x 15 min. (minutes), massaged wrist, good circulation..."
5. 1/12/11 at 0200 "....wrist restraints secure, will monitor frequently..."
6. 1/12/11 at 0400 "....Loosened restraints, massages hands and wrist, circulation adequate..."
7. 1/12/11 at 0745 "....Soft wrist restrains released . Good circulation to hands bilaterally..."
8. 1/12/11 at 0800 "....Soft restraints now reapplied..."9. 1/12/11 at 1100 ".....restraints released. Then reapplied shortly after. Good circulation noted. Will continue to monitor..."
10. 1/12/11 at 1603 "....Wrist restrains remove and reapplied..."
11. 1/12/11 at 1950 "....Soft wrist restraints released and reapplied. Hands warm to touch..."
12. 1/12/11 at 2200 "....Released soft wrist restraints. Soft wrist restraints reapplied..."
13. 1/13/11 at 0002 "....soft wrist restraints removed and reapplied..."
14. 1/13/11 at 0200 "....Soft wrist restraints removed then reapplied. Hands wart to touch..."
15. 1/13/11 at 0412 "....Soft wrist restraints removed then reapplied. Hands warm to touch..."
16. 1/13/11 at 0632 "....Soft wrist restraints removed then reapplied. hands warm to touch..."
17. 1/13/11 at 1000 "....Wrist restraints removed and reapplied..."
18. 1/13/11 at 1200 "....Wrist restraints removed and reapplied..."
19. 1/13/11 at 1400 "....Wrist restraints removed and reapplied..."
20. 1/13/11 at 1600 "....Wrist restraints removed and reapplied..."
21. 1/13/11 at 1800 "....Wrist restraints removed and reapplied..."
22. 1/13/11 at 2010 "....Soft wrist restrains removed and reapplied. Hands warm to touch..."
23. 1/13/11 at 2200 "....Soft wrist restraints removed and reapplied..."
24. 1/14/11 at 0000 "....Soft wrist restraints removed and reapplied. Hands warm to touch..."
25. 1/14/11 at 0400 "....Soft wrist restraints removed then reapplied..."
26. 1/14/11 at 0630 "....Soft wrist restraints removed/reapplied. Hand warm to touch...."

During an interview on 2/3/11 at 2:15 PM, Employee Identifier (EI) #1, the Director of Nurses/Assistant Administrator, confirmed the soft wrist restraints had been applied from 1/10/11 through 1/14/11 and the only order for restraints was the PRN (as needed) order on 1/9/11.

Based on medical record (MR) review and an interview with Employee Identifier (EI) # 1, Director Of Nursing /Assistant Administrator, it was determined the hospital failed to ensure the hospital had established a policy for wound asessment and wound care.The hospital also failed to ensure orders were obtained and clarified for 2 of 2 patients with wounds. This affected MR #14 and #16 and had the potential to affect all patients serviced by this hospital requiring wound care.

Findings:

1. The agency could not produce a policy for wound measurement or assessment.

2. MR #14 was admitted to the agency 1/31/11 at 4:57 PM with diagnoses including Cellulitis Right Foot and Diabetes Mellitus. Review of the Physician's admitting orders dated 1/31/11 at 6:55 PM revealed orders for the Skilled Nurse (SN) to "clean (the patient's) feet with Betadine and saline and apply Bactroban two times a day."

Review of the Nursing Admission Assessment dated 1/31/11 at 6:55 PM revealed the SN documented the patient had an ulcer on the right foot and that the foot was also red and swollen. The first documentation by the SN of wound care was noted 2/1/11 at 2:15 PM as follows: "Feet soaked in Betadine. Rinsed with normal saline and dried. Bactroban applied. 4 x 4's (gauze) between toes. Feet dressed with 4x4 & wrapped with Kling." There was no documentation of an assessment of the bilateral lower extremities or measurement of the ulcer to the right foot.

There was no documentation the Physician was notified to clarify the specific type of wound care to be done.

Further review of the MR revealed the SN documented on 2/1/11 at 8:00 PM wound care as follows: "Both feet dressed, Kling wrapped." There was no documentation to include the type of wound care provided or an assessment of any wounds on the bilateral lower extremities.

Review of the Physician's Orders on 2/1/11 revealed an order for warm Betadine soaks to both feet every shift. The time the order was written was not documented. There was no documentation in the Patient Progress Note by the SN after 2/1/11 at 6:00 PM.

Observation of wound care by the RN on 2/3/11 at 8:15 AM revealed the patient had three wounds; two wounds on the right foot and one wound on the left lateral lower leg. Both feet were soaked in Betadine and warm water for 10 minutes. The pans containing the betadine solution were placed on the floor on a used pad from the patient's chair. The patient's feet were dried using the pad which was on the floor and the areas between the toes were not dried. Cotton balls were then placed between the patient's toes on the right foot. The Bactroban ointment was applied to all the wounds and covered with 4 by 4 gauze. The bilateral lower extremities were wrapped with Kling and secured with tape. There was no documentation the physician was notified of any additional wounds on the lower extremities.
There was no documentation the wounds had been measured since the patient's admission.

3. MR # 16 was admitted to the agency 1/20/11 at 1149 with diagnoses including Altered Level Of Consciousness and Respiratory Distress (possible aspiration). Review of the admission assessment by the Licensed Practical Nurse (LPN) revealed the nurse documented the patient had a sacral decubitus ulcer. There was no documentation of the size of the decubitus.

An interview conducted 2/3/11 with EI #1 and EI #2, Administrator, and EI #4, Quality Assurance Manager, verified the agency had failed to ensure the agency had a clear policy for wound measurements and assessments and to ensure orders were obtained for specific wound care.

Based on review of medical records, review of the Alabama Nurse Practice Act and staff interviews, it was determined the hospital failed to assure the initial nursing assessment was completed by a Registered Nurse (RN). This affected 3 of 16 medical records (MR) reviewed and 1 of 30 Emergency Room Records (ER). This affected MR # 4, # 15, # 16 and ER # 9. This had the potential to affected all patients admitted to the hospital.

Findings include:

Code of Alabama 1975
Nurse Practice Act
34-21-1. Definitions.

a. Practice of Professional Nursing. "The performance, for compensation, of any act in the care and counseling of persons or in the promotion and maintenance of health and prevention of illness and injury based upon the nursing process which includes systematic data gathering, assessment, appropriate nursing judgment and evaluation of human responses to actual or potential health problems..."

b. Practice of Practical Nursing. ..."Such practice requires basic knowledge of the biological , physical and behavioral sciences and of nursing skills but does not require the substantial specialized skill, independent judgement and knowledge required in the practice of professional nursing."

1. MR # 4 was admitted to the hospital on 1/30/11 with a diagnosis of Gastrointestinal (GI) bleed and anemia.

Review of the initial nursing assessment revealed the assessment was performed by the licensed practical nurse (LPN) and not the registered nurse (RN).

During an interview on 2/3/11 at 2:15 PM, Employee Identifier (EI) # 1, Director of Nurses/Assistant Administrator, confirmed an RN did not perform the initial nursing assessment.




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2. Emergency Room Record #9 was admitted to the hospital on 11/23/10 with diagnoses including Infected Stasis Ulcer.

Review of the initial nursing assessment revealed the assessment was performed by the LPN and not the RN.

3. MR #15 was admitted to the hospital on 11/22/10 with diagnoses including Anemia and Thrombocytopenia.

Review of the initial nursing assessment revealed the assessment was performed by the LPN and not the RN.

4. MR #16 was admitted to the hospital on 1/20/11 with diagnoses including Altered Level Of Consciousness and Respiratory Distress.

Review of the initial nursing assessment revealed the assessments were performed by the LPN and not the RN.

During an interview on 2/3/11 at 2:15 PM, Employee Identifier (EI) # 1, Director of Nurses/Assistant Administrator, confirmed the above initial nursing assessments were not performed by the RN.

Based on record reviews, review of hospital policies and staff interviews, it was determined the hospital failed to ensure the patient's history and physical(H&P) was completed and on the patient's medical record (MR) within 24 hours after admission. This affected 4 of 16 medical records reviewed (MR # 8, # 9, # 11 and #12).

Findings include:

Facility Policy

Deficient Charts

".........we must have all charts completed within the allotted time frame: H&P's must be dictated and on the charts within 23 hours of admission....."

1. MR # 8 was admitted to the hospital on 12/28/10 with the diagnosis of Malfunction of PEG ( Percutaneous Endoscopic Gastrostomy) tube.

Review of the H&P revealed it was not dictated and transcribed until 1/3/11.

During an interview on 2/3/11 at 2:15 PM, Employee Identifier (EI) # 1, the Director of Nurses/Assistant Administrator, confirmed the H&P was not completed within 24 hours of admission.

2. MR # 9 was admitted to the hospital on 1/9/11 with the diagnoses of Urinary Tract Infection and Dehydration.
Review of the H&P revealed it was not dictated and transcribed until 1/13/11.

During an interview on 2/3/11 at 2:15 PM, EI # 1 confirmed the H&P was not completed within 24 hours of admission.


3. MR # 11 was admitted to the hospital on 1/13/11 with GI (gastrointestinal) bleed.

Review of the H&P revealed it was not dictated and transcribed until 1/18/11.

During an interview on 2/3/11 at 2:15 PM, EI # 1 confirmed the H&P was not completed within 24 hours of admission.


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4. MR #12 was admitted to the hospital 12/28/10 with Pneumonia.

Review of the medical record revealed the patient's Admission History and Physical was dictated by the Physician on 1/6/11.

This was confirmed in an interview with EI#1 on 2/3/11 at 2:00 P.M.

Based on observations during a facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

Based on medical record review, review of facility policy and staff interviews, it was determined the hospital did not ensure 3 of 4 patients discharged to Home Health were given a list of available Home Health Agencies to choose from. This affected medical record (MR) # 5, # 6 and # 10 and had the potential to effect all patients served.

Findings include:

Facility Policy

Home Health Referrals

2. Procedure for referral

B. Copies list of agencies in home area of patient from Freedom of Choice manual and give to patient and/or family.

C. Once they have chosen the agency they desire, have them sign the Freedom of Choice form. If the patient has had previous Home Health services, and expresses no problems with care, they may choose to return to that agency, Freedom of Choice form must still be signed.


1. MR # 5 was admitted to the hospital on 12/28/10 with diagnoses of Dysphagia, Weakness and Atrial Fibrillation.

Review of the MR revealed the patient was discharged home on 1/5/11 to be followed by Home Health. There was no documentation in the MR the patient was given a list of Home Health Agencies to choose from and there was no Freedom of Choice Form in the MR.

During an interview on 2/3/11 at 2:15 PM, Employee Identifier (EI) # 1, the Director of Nurses/Assistant Administrator confirmed there was no documentation the patient was given a list of Home Health Agencies and no Freedom of Choice Form in the MR.

2. MR # 6 was admitted to the hospital on 11/09/10 with diagnosis of Clinical Evidence of Right Hemispheric Cerebral Vascular Accident with Continued Weakness of Left Lower Extremity.

Review of the MR revealed the patient was discharged home on 11/10/10 to be followed by Home Health. There was no documentation in the MR the patient was given a list of Home Health Agencies and no Freedom of Choice Form in the MR.

During an interview on 2/3/11 at 2:15 PM, EI # 1 confirmed there was no documentation the patient was given a list of home health agencies to choose from and no Freedom of Choice Form in the MR.

3. MR # 10 was admitted to the hospital on 1/19/11 with diagnosis of Pneumonia.

Review of the MR revealed the patient was discharged home on 1/24/11 to be followed by Home Health. There was no documentation in the MR the patient was given a list of Home Health Agencies and no Freedom of Choice Form in the MR.

During an interview on 2/3/11 at 2:15 PM, EI # 1 confirmed there was no documentation the patient was given a list of Home Health Agencies to choose from and no Freedom of Choice Form in the MR.

Based on observations, review of hospital policies and staff interviews, it was determined the hospital failed to have a policy to assure the operating rooms (OR) were monitored for safe parameters of humidity and temperature for 2 of 2 operating rooms. This had the potential to negatively affect all patients served.

Findings include:

A tour of the Surgery Department was conducted on 2/2/11 at 10:45 AM. At 10:50 AM the surveyor asked Employee Identifier (EI) # 3, the Registered Nurse/Operating Room Manager, if there was documentation of the monitoring of the temperature and humidity for the 2 operating rooms. EI # 3 stated he/she was not aware of any temperature or humidity monitoring of the operating rooms.

On 2/2/11 at 2:30 PM the surveyor reviewed the hospital policies and procedures for the surgical/operating department. The surveyor was unable to find any policies regarding monitoring of the temperature or humidity in the operating rooms.

During an interview on 2/2/11 at 2:40 PM, EI # 1, the Directror of Nurses/Assistant Administrator, and EI # 2, the Administrator, confirmed the temperature or humidity in the operating rooms were not being monitored.


During an interview on 2/2/11 at 2:40 PM, EI # 1, the Director of Nurses/Assistant Administrator, and EI # 2, the Administrator, confirmed the temperature or humidity in the was not being monitored.