HospitalInspections.org

Based on review of medical records (MR), hospital policy and interviews with administrative staff, it was determined the facility failed to obtain a signed informed consent for patients admitted to swing beds prior to providing services/ care for 2 of 18 MR and 2 of Emergency Room (ER) records reviewed

This affected MR # 6, # 3, ER# 18 and # 19 and had the potential to negatively affect all patients served by the facility.

Findings include:

Hospital Policy: Admission Process
Policy Description: Inpatient/ Observation/ Swing Bed Admission
Revised Date: 04/17/2008

Admission Process

1. Admissions when arriving at work. (Admissions from the day before MUST be done before the Daily reports are run).

...

2. ...

...

2.4 Take the admissions packet with all appropriate paper work and obtain the patient or grantor's signature. Verify demographics with the patient/ family for accuracy. When returning to the office, make necessary corrections, if applicable.

Verify the accuracy of the insurance information and make a copy of the insurance card (s), if available.

Only then have the patient to sign the Consent and the Patient Concerns form. ...


1. MR # 6 was admitted to the facility 3/15/15 with the diagnoses including Urinary Tract Infection, Cough, Urinary Retention and Hypoxia.

Review of Form 101- Admit Form 3/22/16 revealed there was no documentation the patient signed the following documents on admission; Consent for Medical Treatment, Advance Directives, Release of Medical Information, Patient or family Concerns, Financial Agreement and Assignment of Insurance benefits, and Acknowledgement.

Further review of the Form 101 revealed the Hospital Representative signed, marked a line across the page and wrote "patient not able to sign" and sign.

An interview was conducted on 3/21/16 with Employee Identifier (EI) # 2, Registered Nurse (RN), who confirmed the above mentioned findings.


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2. MR # 3 was admitted to the facility 3/17/15 with the diagnoses including L(Lumbar) 3 Compression Fracture, Mild Alzheimer's Disease, Chronic Obstructive Pulmonary Disease (COPD), Diabetes, Asthma and Hx (History) of TIA (Transient Ischemic Attack).

Review of Form 101- Admit Form 3/21/16 revealed there was no documentation the patient signed the following documents on admission; Consent for Medical Treatment, Advance Directives, Release of Medical Information, Patient or family Concerns, Financial Agreement and Assignment of Insurance benefits, and Acknowledgement.

An interview was conducted on 3/23/16 at 1:50 PM with EI # 12, Admissions Clerk, who confirmed the above mentioned findings.

Further interview was conducted on 3/23/16 at at 1:20 PM with EI # 1, Certified Registered Nurse Practitioner (CRNP)/Interim Director of Nurses and EI # 2 who stated that the business office personnel is responsible for getting the consents signed. EI # 1 and # 2 then stated that the business office closes daily at 4:30 PM. From Firday at 4:30 PM until Monday at 8:00 AM the business office is closed.



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3. ER # 18 was admitted to the ED on 2/19/16 with the chief complaint of Foreign Body in Throat.

Review of the MR revealed there was no documentation of a signed consent for treatment.

An interview was conducted on 3/23/16 at 8:28 AM with EI # 1, and verified the staff failed to obtain a signed consent for treatment.

4. ER # 19 was admitted to the ED on 2/20/16 with the chief complaint of Physical Assault.

Review of the MR revealed there was no documentation of a signed consent for treatment.

An interview was conducted on 3/23/16 at 8:28 AM with EI # 1, and verified the staff failed to obtain a signed consent for treatment.

Based on review of policy and procedure, Centers for Disease Control and Prevention, observations and interview, it was determined the facility failed to ensure:

a) all medications in patient treatment areas were not expired.

b) all medications in use were correctly labeled.

This had the potential to negatively affect patients receiving care at this facility.

Findings include:

Centers for Disease Control and Prevention

4. "When should multi-dose vials be discarded?

Medication vials should always be discarded whenever sterility is compromised or questionable.
In addition, the United States Pharmacopeia (USP) General Chapter 797 [16] recommends the following for multi-dose vials of sterile pharmaceuticals:
If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial."

Facility Policy: Medication Room Inspection

"Pharmacy personnel will make a monthly inspection of all pharmacy items stored on Nursing Stations, Specialty Units and other locations where drugs may be stored.

The following checks will be accomplished during the inspection.

Check
1. Unauthorized items ... Action: return to Pharmacy
2. Outdated items ... Action: return to Pharmacy for replacement
3. Label Conditions ... Replace ...
5. Crash Carts ... Re-stock, remove and replace outdated items."


1. During a tour of the Pharmacy on 3/21/16 at 9:40 AM the surveyor observed the following expired medications in the medication refrigerator:

Promethazine Hydrochloride (HCL) Suppositories 25 milligrams (mg) times (x) 1 box expired (exp) 6/14 and (&) 1 box exp 4/15.

Promethazine HCL Suppositories 12.5 mg x 1 box exp 7/15.

Succinyllcholine 200 mg (20 mg / milliliter [ml]) x 19 bottles exp 3/1/16.

Atracurium 250 mg / 5 ml x 2 boxes: 1 box exp 12/17/14 & 1 box exp 1/23/15.

An interview was conducted on 3/21/16 at 10:00 AM with Employee Identifier (EI ) # 9, Director of Pharmacy, who verified the above medications were expired.

2. During a tour of the Outpatient Therapy Department on 3/22/16 at 9:55 AM the surveyor observed the following medications in the medication refrigerator open and not dated:

Acetic Acid (Liquid): Prescription (Rx) dated 11/18/15
Dexamethasone (Liquid): Rx dated 12/12/15.

There was no expiration date noted on the bottles.

An interview was with EI # 11, Director of Rehab (Rehabilitation) on 3/22/16 at 10:30 AM. EI # 11 called the pharmacy regarding the expiration of the above mentioned drugs. EI # 11 stated, "The pharmacist said not to use them past 60 days". EI # 11 then stated the medications should have an expiration date noted on the bottle.



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3. During a tour of the Emergency Department (ED) on 3/21/16 at 9:05 AM with EI # 5 RN, the surveyor observed the following medications in the medication refrigerator open and not dated:

Novolin Regular Insulin 3 ml vial.
Diltiazem Hydrochloric Acid (HCL) 5 mg/ ml.

The following medications were opened, not dated and expired:

Acetylcysteine Solution 20% 30 ml vial exp 7/10/15.
Humulin 70/30 Insulin 3 ml vial exp 3/14.
Novolin N Insulin 3 ml vial exp 1/14.

Further observation of the medication room revealed the following medications opened and not dated:

Lidocaine 1% 50 ml vial.
Lidocaine 2% 50 ml vial.
Amidate 20 ml vial.
Sterile Water 50 ml vial.
Mastisol 15 ml vial.
Cleocin 2 ml vial.
Linocin 10 ml vial.
Normal Saline (NS) 0.9% Sodium Chloride 1000 ml.

The following medications were opened, not dated, and expired:

Dexamethasone Sodium Phosphate 0.5 ml bottle expired 8/14.
Phenylephrine HCL Opthalmic Solution 10% 5 ml expired 4/15.
Bactrim Suspension 6 ounce (oz) exp 9/12.
Furosemide 100 mg /ml 10 ml vial exp 2/16.
Sterile Water 10 ml syringe exp 3/15.
29- Meclizine 25 mg tablet exp 2/16.
Magic Mouthwash 60 ml bottle exp 1/19/14.

The following medications were opened and labeled with a date greater than 30 days:

ER exam room # 1:

NS 1000 ml bottle labeled with the open date of 12/15.
Sterile Water 1000 bottle labeled with open date of 12/15.

ER exam room # 2:

NS 1000 ml bottle labeled with the open date of 10/15.
Sterile Water 1000 ml bottle labeled with the open date of 1/15.

The following medications were observed on top of the ER crash carts:

2- Albuterol Sulfate 3 ml vials were found lying on top of the crash cart.
8- Xopenex Inhalation Solution 1.25 mg/ 3 ml vials.
12- Atrovent Inhalation Solution 0.5 mg /3 mg/ 3 ml vials.

An interview was conducted on 3/23/16 at 8:28 AM with EI # 1, and verified the staff failed to label medication vials when opened, store medications properly, and monitor/ dispose of expired medications per policy.

Based on United States Health Public Food Code 2009 regulations, observations and interview, it was determined the hospital failed to ensure food was stored in a safe and sanitary manner.

This had the potential to negatively affect all patients.

Findings include:

United States Health Public Food Code 2009

3-501.17 Ready-to-Eat, Potentially Hazardous Food
(Time/Temperature Control for Safety Food),
Date Marking.
...commercially processed food open and hold cold
(B) Except as specified in (D) - (F) of this section, refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety...

(C) A refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) ingredient or a portion of a refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is subsequently combined with additional ingredients or portions of food shall retain the date marking of the earliest- prepared or first prepared ingredient.

(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include:...
(2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section;
(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section...

Storing
4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles.

(A) Except as specified in ¶ (D) of this section, cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored:

(B) Clean equipment and utensils shall be stored as specified under ¶ (A) of this section and shall be stored:

(1) In a self-draining position that allows air drying; and

(2) Covered or inverted.


A tour of the Dietary Department was conducted on 3/21/16 at 9:10 AM. The surveyor observed the following in the refrigerator:

a. Nine (9) Ham and Cheese sandwiches covered with a plastic without a label or date.

c. Styrofoam plate containing oatmeal, and blended scrambled eggs without a label or date.

Review of the refrigerator/freezer temperature logs for March 2016 revealed no documentation the temperatures were checked as follows:

Walk in Freezer: 3/3/16
Reach in Refrigerator: 3/3/16
Walk in Refrigerator: 3/3/16 and 3/4/16

Also during the tour of the Dietary Department on 3/21/16 at 11:25 AM, the surveyor observed multiple small and medium steam table pans which were wet, stacked upon each other setting on the shelf.

An interview was conducted on 3/21/16 at 11: 25 AM with Employee Identifier (EI) # 4, Dietary Manager/Registered Dietitian, who verified the aforementioned findings.

Based on observations during 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. This had the potential to affect all patients served by the hospital.

Findings include:

Refer to Life Safety Code violations for findings.

Based on observations, review of facility policy and interviews with facility staff it was determined the facility failed to

a) Ensure supplies available for patient use were not expired.

b) Ensure equipment was monitored to maintain safety of patients and staff.
c) Provide preventative maintenance on all equipment in the Swingbed Therapy Unit and Endoscopy Lab as directed per the facility policy.
d) Ensure safe operation and integrity of emergency crash carts. This affected 4 of 5 emergency crash carts in the facility.

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

Findings include:

Facility Policy: Floor Stock Procedure (Medications):

"... In addition to the crash carts and medication closet, some drugs will need to be stores in the refrigerator. Proper storage temperatures will be monitored and a daily temperature check will be performed."

Facility Policy: Equipment Management Plan

"Policy: Bibb Medical Center's Equipment Management Plan will provide and maintain an equipment management program that promotes the safe and effective use of equipment...

Assessing and Minimizing Clinical Physical Risks of Equipment Through Inspection, Testing and Maintenance:

... Preventative maintenance and safety inspections will be completed on all equipment in the program at least annually."

Facility Policy:
Title: Crash Cart- Checking of
Reviewed 2/9/07

Policy:

1. All crash cars will be checked at the beginning of each shift daily to ensure that all emergency equipment is present and in proper working order.

2. All crash carts will be inventoried monthly for outdated or missing materials...

Procedure:

1. All crash carts will be checked:
a. At the beginning of each shift for...
(3) Pediatric and adult Ambu bags secured to the cart..."



1. During a tour of the Pharmacy on 3/21/16 at 9:40 AM the surveyor requested the last 3 months (January to March 2016) temperature logs for the medication refrigerator. Employee Identifier (EI) # 9, Director of Pharmacy stated that the person that was responsible for those was out today. There were no logs submitted on 3/21/16.

On 3/22/16 at 8:55 AM Employee Identifier (EI) # 10, Pharmacy Technician, submitted the aforementioned logs.

Review of the March 2016 medication temperature log revealed there was no documentation of temperatures logged from 3/1/16 - 3/21/16, (which was 21 days).

An interview was conducted on 3/23/16 at 1:07 PM with EI # 1, Certified Registered Nurse Practitioner, Interim Director of Nurses, who verified the aforementioned findings.

2. During a tour of the Outpatient Therapy Department on 3/22/16 at 9:55 AM the surveyor requested the last 3 months (January to March 2016) temperature logs for the medication refrigerator and the cold pack unit.

Review of the temperature logs for the medication refrigerator revealed there was no documentation of temperatures for the following dates:

January: 1/1/16 - 1/31/16 ( which was 31 days).

February: 2/1/16, 2/5/16, 2/11/16, 2/12/16 and 2/26

March: 3/1/16

The surveyor requested the temperature log for the cold pack unit: There was no temperature log submitted for the cold pack unit.

An interview was conducted on 3/22/16 at 10:30 AM with EI # 11, Director of Rehab (Rehabilitation), who confirmed the aforementioned findings.

3. During a tour of the Swingbed Therapy Unit on 3/22/16 at 11:10 AM the surveyor observed the following equipment did not have documentation preventative maintenance had been performed as directed per the facility policy:

Stationary Bike: No Preventive Maintenance (PM) Sticker
Nuvo Lite Oxygen (O2) Concentrator: PM sticker dated 11/15/14
High/Low Bed: PM sticker dated 11/15/14

An interview was conducted on 3/22/16 at 11:25 AM with EI # 11 who confirmed the above findings.



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4. During a tour of the Emergency Department (ED) on 3/21/16 at 9:05 AM with EI # 5, Registered Nurse (RN).

During the tour review of the February and March Medication refrigeration logs and Crash Cart logs revealed:

Review of the medication refrigerator logs revealed there was no documentation of temperatures for the following dates: 2/21/16, 2/29/16, 3/1/16, and 3/5/16 to 3/16/16 (12 days).

There was no initials or legend as to who documented the temperatures for 21 of the 27 temperatures posted on the February log.

There was no initials or legend as to who documented the temperatures for the 7 of the 7 temperatures posted on the March log.

Exam Room 1:

Review of the February Crash Cart/ Emergency Equipment Check List (CC Checklist) revealed no documentation the crash cart was checked for the following shifts: 2/1/16 PM, 2/6/16, 2/7/16, 2/10/16, 2/14/16 AM, 2/18/16 AM, 2/18/16 PM, 2/19/16 PM, 2/20/16 PM, 2/21/16 AM & PM, 2/22/16 PM, 2/23/16 PM, 2/24/16 PM, 2/25/16 PM, and 2/28/16 AM & PM for a total of 17 shifts.

Review of the March CC Checklist revealed the staff failed to document the crash cart was checked for the following shifts: 3/3/16 - 3/5/16 PM, 3/6/16 and 3/13/16 AM & PM for a total of 7 shifts thus far.

ER Exam Room # 2

Review of the February Adult CC Checklist revealed no documentation the crash cart was checked for the following shifts: 2/1/16 PM, 2/7/16 PM, 2/9/16 PM, 2/10/16 PM, 2/14/16 to 2/19/16 AM, 2/21/16 AM & PM, 2/22/16 PM, 2/24/16 PM, 2/28/16 AM & PM for a total of 16 shifts.

Review of the March Adult CC Checklist revealed no documentation was checked for the following shifts:
3/3/16 to 3/5/16 PM, 3/6/16 AM & PM, 3/7/16 PM, 3/13/16 AM & PM for a total of 8 shifts thus far.

3. Review of the February Pediatric CC Checklist revealed no documentation the crash cart was checked for the following shifts:
2/1/16 AM & PM, 2/2/16 AM, 2/3/16 AM, 2/7/16 PM, 2/9/16 PM, 2/10/16 PM, 2/14/16 AM & PM, 2/15/16 AM, 2/16/16 AM, 2/17/16 AM & PM, 2/18/16 AM, 2/19/16 AM, 2/21/16 AM & PM, 2/23/16 PM, 2/24/16 PM, 2/28/16 AM & PM for a total of 19 shifts.

Review of the March Pediatric CC Checklist revealed no documentation the crash cart was checked for the following shifts: 3/3/16 PM, 3/4/16 PM, 3/5/16 PM, 3/6/16 AM & PM, 3/7/16 PM, 3/13/16 AM & PM for a total of 9 shifts thus far.

In an interview conducted on 3/23/16 at 8:28 AM with EI # 1, verified the staff failed to document daily temperatures and initial the temperatures that were posted and the check the crash cart each shift.

5. During a medication pass on 2/22/16 at 9:30 AM an inspection of the nursing floor crash cart. Observation of the crash cart logs revealed expired items and the crash cart was not checked by staff each shift.

The following medical items were observed to be expired

10 french (fr) Satin Slip Stylet exp 11/13.
6 fr Stylet exp 2/2004.
King Laryngeal Tube (KLT) size 4 exp 12/13.
KLT size 5 exp 7/14.
22 gauge (gu) Intravenous (IV) Catheter exp 10/15.
22 gu IV Catheter exp 2/16.
Tegaderm dressing 2 1/2 inch (in) X 2 3/4 in exp 5/2005.
5- packages Defibrillator Pads 9 in X 6 in exp 5/2003.
26- Medi Trace Electrocardiogram (ECG) foam pads exp 11/15.
16 fr Foley Catheter Tray exp 10/12.

The aforementioned items were verified and provided to EI # 2, RN at the time of the observation.

There was no pediatric Ambu bag found on the crash cart.

Review of the February CC Checklist revealed no documentation the crash cart was checked for the following shifts PM shifts: 2/1/16 to 2/4/16, 2/6/16, 2/8/16, 2/12/16 to 2/23/16, and 2/27/16 to 2/29/16. AM shifts: 2/24/16 and 2/25/16 for a total of 22 shifts.

Review of the March CC Checklist revealed no documentation for the following PM shifts: 3/1/16 to 3/4/16 PM, 3/7/16 to 3/11/16, 3/14/16 to 3/20/16 for a total of 16 shifts.


An interview was conducted on 3/23/16 at 8:28 AM with EI # 1, and verified the staff failed to ensure expired items were removed and were not available for patient use and the staff failed to ensure the crash carts were checked every shift.



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6. A tour of the Labor and Delivery Department was conducted on 3/22/16 at 8:30 AM with EI # 12, Obstetric/ Labor and Delivery Registered Nurse. The following items found in the Crash Cart Box were expired:

1. Angiocath gauze 1.1 x 25 mm (millimeter) x 3 expired 3/2013

2. Laryngeal Tube Size 3 x 1 expired 12/2014

3. Laryngeal Tube Size 4 x 1 expired 10/2014

4. Laryngeal Tube Size 5 x 1 expired 11/2014

An interview was conducted with EI # 12 on 3/22/16 at 8:25 AM, who confirmed the above mentioned findings.

Based on observations, review of policies and procedures, National Institute for Occupational Safety and Health and interviews, it was determined the facility failed to ensure:

a) Sharps containers were properly secured and replaced when the fill line was reached.

b) Staff performed hand hygiene prior to preparing medications and upon entering and exiting the patient's room.

c) Staff cleaned equipment (glucometer) after patient use.

d) Staff discarded devices labeled for single use by manufacturer are discarded after use and not used for more than 1 patient.

This affected Medical Record (MR) # 3 and had the potential to negatively affect all patients and staff at this facility.

Findings include:

Facility Policy: Handwashing

"Policy: All employees will be aware of (and) utilize proper handwashing technique.

Purpose: To prevent the spread of infection.

Procedure:

1. All employees will be aware of and utilize proper handwashing technique.

2. Hands must be washed before and after patient contact, and before initiating any procedure."

National Institute for Occupational Safety and Health:

Topic: Selecting, Evaluating, and Using Sharps Disposal Containers

"Sharps Disposal Containers

A. Performance Criteria

1. Functional criteria

...

Stability: Containers ... should be stable when placed on a horizontal surface ... Some manufactures provide trays, holders, or enclosures to stabilize their containers in certain applications.

...

2. Accessibility criteria

... Examples of inappropriate installation include placement ... where people might sit or lie beneath the container."

Facility Policy: Disposal of Used and Contaminated Sharps

"It is the policy of the Bibb Medical Center that all contaminated needles and sharp objects be ... These containers shall be located in each patient room and on all nursing units in areas specially designated."

1. An observation was conducted by the surveyor on 3/21/16 at 11:10 AM to observe Employee Identifier (EI) # 13, Registered Nurse (RN) perform a blood glucose with a glucometer machine on MR # 3. EI # 13 performed the blood glucose and proceeded to place the glucometer machine back in its container without cleaning it past use.

An interview was conducted on 3/23/16 at 1:20 PM with EI # 2, Registered Nurse and EI # 1, Certified Registered Nurse Practitioner (CRNP)/Interim Director of Nurses, who stated the glucometer should have been cleaned with alcohol past use.

2. An observation was conducted by the surveyor on 3/22/16 at 8:25 AM with EI # 14, RN observe medication administration to MR # 3. EI # 14 entered the medication room and prepared 12 medications, which included oral medications (10), nasal spray and inhalers. EI # 14 emptied each of the oral medications into his/her hand and placed them into a medicine cup. EI # 14 then preceded to MR # 14's room and administered the medications. EI # 14 did not perform hand hygiene prior to preparing the medications, upon entering the MR # 14's room or leaving the room.

An interview was conducted on 3/23/16 at 1:20 PM with EI # 1 and EI # 2 who verified the staff should perform hand hygiene prior to preparing medications and upon entering and leaving the patient rooms.

3. During a tour of the Outpatient Therapy Department on 3/22/16 at 9:55 AM with EI # 11, Director of Rehab (Rehabilitation), the surveyor observed a sharps container 3/4 full sitting on the "Plinth" bed in an exam room used by the Speech Language Pathologist and the Specialty Clinic. EI # 11 stated that the Speech Language Pathologist see's pediatrics in this room.

The sharps container was not secure and out of reach of children and other patients may sit or lie down as directed per the National guidelines.

An interview was conducted on 3/23/16 at 1:20 PM with EI # 1 and EI # 2 who confirmed the sharps container should be anchored on the wall.






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4. During a tour of the Emergency Department (ED) on 3/21/16 at 9:05 AM with EI # 5, RN, the surveyor observed in the medication room:

An overfilled sharps container past the over-fill live and the following medical supplies that were labeled for single use opened and were not discarded after use.

Iodoform packing gauze opened and partially used.
Steri Strip wound closures (3 packages) opened and partially used.
Ear tray contained the following metal instruments opened and not packaged 2 speculums, tweezers, scissors, and a loop instrument.

In an interview conducted on 3/23/16 at 8:28 AM with EI # 1, and verified the staff failed to dispose dirty sharps as indicated and dispose of used medical supplies labeled for single use items after patient use.

5. During a tour of the Endoscopy Department on 3/21/16 at 9:35 AM with EI # 15, RN, the surveyor observed a sharps container filled past the recommended fill line.

In an interview conducted on 3/23/16 at 8:28 AM with EI # 1, and verified the staff failed to dispose dirty sharp as indicated.

Based on review of medical records (MR) and interview with admininstrative staff, it was determined the hospital failed to ensure patient's history and physical examination were performed no more than 30 days before or 24 hours after admission or registration.

This affected 2 of 2 records reviewed for outpatient endoscopic procedures including MR # 14 and MR # 15, and had the potential to negatively affect all patients served by the hospital.




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1. MR # 15 was admitted to Outpatient Services on 1/15/16 for the surgical procedures of Esophagogastroduodenoscopy (EGD) and Colonoscopy.

Review of the MR revealed the H & P was performed on 12/8/16. There was no documentation the H & P had been reviewed or updated prior to the procedure being performed on 1/15/16.

In an interview conducted on 3/23/16 at 9:05 AM with EI # 1, Certified Registered Nurse Practitioner (CRNP)/Interim Director of Nurses, verified the aforementioned findings.

2. MR # 14 was admitted to Outpatient Services on 1/25/16 for the surgical procedure of a Colonoscopy.

Review of the MR revealed the H & P was performed on 11/10/15. There was no documentation the H & P had been reviewed or updated prior to the procedure being performed on 1/25/16.

In an interview conducted on 3/23/16 at 9:05 AM with EI # 1, Certified Registered Nurse Practitioner (CRNP)/Interim Director of Nurses, verified the aforementioned findings.

Based on review of facility policy, medical records (MR), and interview with the admininstrative staff, it was determined the facility failed ensure patients properly executed and signed Consent for Surgical Procedure for 2 of 2 MR's reviewed. This affected MR #8 and MR # 15, and had the potential to negatively affect all patients receiving services at the facility.

Findings include:

Hospital Policy

Subject: Consent - Informed and Implied
Revised date: 4/16/08

Policy:

"Informed Consent

The patient will be informed of procedures, potential adverse reaction and potential outcomes:

The patient shall sign a written consent outlining invasive procedures and surgery...

Bibb Medical Center staff will obtain written consent from the patient prior to the procedure."


1. MR # 8 was admitted to the hospital on 2/23/16 with the diagnoses including Cellulitis, Diabetic Foot Ulcer, Diabetes mellitus and Hypertension.

Review of the Nurses' Note 2/27/16 revealed the patient was given Morphine 2 milligrams (mg) and Zofran 4 mg intravenous prior to Debridement of left foot. Further review of the Discharge Summary 3/1/16 revealed the physician's documentation under Pertinent Procedures the patient had "Excisional debridement of abscess and diabetic foot ulcer.
There was no documentation a consent for surgical procedure was obtained prior to the procedure.

The answers to questions given by the surveyor to Employee Identifier (EI) # 2, Registered Nurse (RN) was answered on 3/22/16 at 2:15 PM. The surveyor requested EI # 2 for a copy of the surgical consent signed by the patient, no signed consent form was provided.


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2. MR # 15 was admitted for an Outpatient Services on 1/15/16 for the surgical procedures of Esophagogastroduodenoscopy (EGD) and Colonoscopy.

Review of the MR revealed the EGD and Colonoscopy Preparation (prep) instructions were prepared, provided and the patient signed the instructions on 1/4/16 for the planned procedure date of 1/15/16.

Further review revealed the Authorization and Consent for Operation/ Procedures (Surgical Consents) as "EGD with possible biopsy and/ or dilatation" and "Colonoscopy c possible biopsy" signed by the patient on 1/4/16.

The surgical prep instructions, surgical consent were prepared and witnessed by Employee Identifier (EI) # 8, Medical Assistant (MA) Specialty Clinic.

Review of the 1/15/16 surgical consents revealed documentation as "EGD with possible biopsy and/ or dilatation" and "Colonoscopy c possible biopsy" and witnessed by EI # 8.

Review of the 1/15/16 Discharge Instructions for the EGD and Colonoscopy revealed the signature for Registered Nurse (RN) Discharging providing the instruction as EI # 8.

In an interview on 3/23/16 at 9:05 AM with EI # 1, Certified Registered Nurse Practitioner (CRNP)/Interim Director of Nurses verified surgical consents should not contain abbreviations, MA's should not provide discharge instructions and was not sure if a MA could or could not witness surgical documents.

Based on review of swing bed records, hospital policy and interview with the Activities Assistant (AA), it was determined the hospital failed to ensure Initial Activities Assessment (IAA) assessment was conducted within 48 hours after Admission.

This affected 2 of 3 medical records (MR) reviewed including MR # 1 and MR # 3, and had the potential to negatively affect all patients served in the swing bed unit.

Findings include:

Swing Bed Policy Manual

Subject: Program Activities
Revision Date: 5/20/2014

Policy:

The Bibb Medical Center Swing Bed Program will provide a program of activities appropriate for all patients admitted to the Skilled Nursing Unit in the Hospital.

Procedure:

Activities will be document the Initial Program Activities within 48 hours after Admission. The plan will be appropriate to each resident on the unit.


1. MR # 1 was admitted to the hospital Swing Bed Unit on 3/11/16 with the diagnoses including Weakness, Fall, Hypertension and Dementia.

Review of the swing bed records on 3/21/16 revealed the IAA was performed on 3/21/16. The assessment was performed 10 days past the 48 hours IAA hospital policy.

Review of the IAA revealed no documentation the AA documented her/ his visit frequencies for the patient.Further review of the swing bed records revealed there were no documentation's the AA visited the patient on 3/14/16, 3/15/16, 3/16/16, 3/17/16, 3/17/16 and 3/18/16.

An interview was conducted on 3/23/16 at 1: 15 PM with Employee identifier (EI) # 3, Activities Assistant, confirmed the above mentioned findings. The AA further stated that he/ she normally visit patients in the swing bed on the first part and last part of the week and as needed.

2. MR # 3 was admitted to the hospital Swing Bed Unit on 3/17/16 with the diagnoses including Lumbar vertebrae 3 Compression Fracture, Mild Alzheimer's Disease and Chronic Obstructive Pulmonary Disease.

Review of the swing bed records on 3/22/16 revealed the IAA was performed on 3/21/16. The assessment was performed 5 days past the 48 hours IAA hospital policy.

Review of the Initial Activties Assessment revealed there was no documentation as to the frequency of visit the AA will be performing.Further review of the swing bed records revealed there were no documentation's the AA visited the patient on 3/18/16.

An interview was conducted on 3/23/16 at 1:15 PM with Employee identifier (EI) # 3, Activities Assistant, confirmed the above mentioned findings. The AA further stated that he/ she normally visit patients in the swing bed on the first part and last part of the week and as needed.