HospitalInspections.org

Based on review of facility policy, complaint files and interviews with staff, it was determined the facility failed to ensure complaints were investigated through to resolution. This affected 3 of 4 complaints reviewed, including Patient Identifier (PI) # 31, PI # 32, and PI # 33, and had the potential to negatively affect all patients receiving care at this facility.

Findings include:

Facility Policy:

Subject: Patient Complaints / Grievance Resolution
Effective Date: 07/2015

I. Purpose: Atmore Community Hospital strives to provide quality medical care in an atmosphere of care and concern for patients / family members / surrogate decision makers / visitors. We encourage patients / family members / surrogate decision makers / visitors to voice any concerns regarding their experience for quick and effective resolution...

III. Procedure...

3. Grievance is defined as: written or verbal complaint that cannot be resolved at the time of complaint by staff present. "Staff Present" includes any hospital staff present at the time of the complaint or who can quickly be at the patient's location (i.e., nursing, administration, nursing supervisors, etc.) to resolve the patient's complaint.

A. Administrative secretary / Departmental Management / Quality Management / Risk Management will be responsible for responding to formal grievances...

D. Grievances made by telephone call or letter from discharged patients will be forwarded to the departmental manager and / or Administrative secretary...

4. Investigation of a Grievance:

A. Administrative will coordinate the investigation, follow-up, and resolution of grievances... with the appropriate Department Manager...

C. Any grievance concerning the quality of care resulting in a negative patient outcome or the substantial risk of negative outcome will be forwarded to Quality Management / Risk Management as needed...

E. Administrative secretary will review all grievances and will forward the appropriate information and recommendations for resolution to Administration and department supervisor.

5. Response:

A. Initial written response acknowledging grievance will be done within seven days by Administration or departmental manager if unable to address or resolve either by telephone or in person.

B. Administrative secretary will notify the complainant of the actions taken on their behalf to investigate the grievance, the results and date of completion of the investigation, and the person to contact if the complainant has any additional concerns. Resolution is expected within 30 days receipt of grievance.

6. Performance Improvement:

A. Grievance reports will be presented to the Performance Improvement Committee for review. Any trends or patterns identified will be analyzed for opportunities for improvement in accordance with the Performance Improvement and Patient Safety Plan.
*****

1. A review of the information, "... Re: Patient family complaint, Patient Name... I received a voice mail yesterday afternoon from... wanting to talk to someone regarding a visit.. brought (PI # 31) to our ED (Emergency Department)... I returned the call to (complainant) today... stated (he/she) brought (PI # 31) in here on Sunday, July 23, 2017 for left knee pain... stated they were triaged and sent back out to the lobby where they waited for 2 - 2 1/2 (2 to 2 and one/half) hours and didn't understand why because there were no ambulances and not many patients... (Complainant) stated when they were finally taken back they were put in a room with an ice machine and you could see everyone (employees & doctor from the room and no kind of emergency was going on... (Complainant) stated (ED Physician) was sitting at the desk rubbing his beard and the staff was literally walking around with nothing to do... they waited another 1 1/2 (one and one/half) to 2 hours in the room before ever seeing the doctor and all this time (patient) was in bad pain... when (ED Physician)... came in he/she pushed around on (patient) knee a little bit and said he/she was going to get an x-ray... (complainant) stated he/she was in the room less than 5 minutes... (complainant) stated the staff kept apologizing for... wait time and they were actually walking around just trying to find stuff to do... (complainant) stated when radiology came and got (patient) they too apologized because (ED Physician) put all of the ED patients x-ray orders in at the same time. (Complainant) stated when (ED Physician)... came back in the room he/she stated he was going to give PI # 31 a steroid shot and (patient) was to follow up with (his/her) primary (Physician) in 1 week... (Complainant) stated he/she felt like (ED Physician) gave PI # 31 the steroid shot because he/she didn't know what else to do.... this was ridiculous because he/she didn't give PI # 31 anything for the pain and they had been waiting for 5 hours in the ED when they weren't even busy... Emailed this complaint to the following... (President)... (ED Medical Director)... (Director of Nursing)... ED Supervisor)... (Ed team leader)..."

Review of the complaint file revealed an email dated July 26, 2017 with documentation related to "complaint" The surveyor review this email documentation and was unable to determine if this was related to the complaint above regarding the care PI # 31 received on 7/23/17 as it was related to safety concerns in the hospital after visiting hours were over and someone running up the stairs.

Review of a document dated 7/26/17 by Employee Identifier (EI) # 8, Emergency Room Manager revealed, "... Spoke with (complainant) regarding (his/her) complaint on July 25, 2017 regarding (PI # 31) visit on July 23 in our emergency room. I stated to (complainant) that I was unable to discuss the care unless I was able to talk with the patient. (Complainant) stated (he/she) understood and... would be back with the patient on August 3, 2017 and asked if (he/she) could give me a call at that time. I was happy to provide (complainant) with my number and (he/she) stated... would get (patient) to call me on August 3rd, 2017. (Complainant) was happy with the conversation and voiced they would call back..."

Review of the letter dated July 27, 2017 revealed EI # 1, Director of Nurses documented a letter to the complainant, which included, "... I am in receipt of your concerns regarding (PI # 31) emergency room visit on July 23, 2017... It is my understanding (EI # 8) has spoken with you briefly and explained that to remain in compliance with privacy laws, she is unable to discuss the care without (PI # 31) permission and the three of you have a call scheduled for August 3rd. Please feel free to contact me in my office at... if you need anything further..."

There was no further documentation related to the complainant's concerns, including the "scheduled" call for August 3, 2017 or a resolution to the complainant's concerns.

An interview was conducted on 4/18/18 at 12:29 PM with EI # 1 and EI # 8 regarding the above complaint. EI # 8 stated the complainant did not call back and she verified this was not documented.


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2. A review of the complaint documentation provided to the surveyor revealed letters related to complaints regarding the care provided to PI # 32 as follows:

PI # 32 was seen in the ED on 04/20/17. PI # 32 came from home via ambulance. PI # 32 had soiled on him/herself and on the sheets of the bed. Nurse was instructed about patient being soiled and sheets also soiled. Complainant stated, "that the nurse just threw another sheet on top of it" after being informed about patient and the sheets being soiled. At discharge, complainant asked nurse for something for patient to sit on in the car so that "poop" would not get on his/her car seats. Complainant was given a small disposable pad for patient to sit on in car.

On 4/27/17 EI # 8, documented letter of speaking with complainant about the complaint and the apology provided by facility.

Further review of this complaint revealed no documentation about results of the investigation involving nursing care provided to PI # 32.


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3. A review of the complaint documentation provided to the surveyor revealed a letter related to complaints regarding the care provided to PI # 33.

The complaint was in regards to "...my 16 year old, who was involved in a motor vehicle accident on July 5, 2017....arriving at the hospital with possible concussion, abdominal pain and bruising from the seatbelt....The ED physician came into the room, asked PI # 33 to move his/her neck from left to right, and then asked the nurse if he/she should get a CT (Computed Tomography) Scan of his/her brain....". The complainant stated PI # 33 should have had a full assessment done first to find out what might have been needed. The CT Scan was normal according to PI # 33. The complainant asked "several nurses if I could speak to the doctor before PI # 33 was discharged and was told the doctor was busy". The complainant is a nurse at the facility for 26 years and stated the ED physician "...did not put a stethoscope on PI # 33 nor did he/she ever touch PI # 33....PI # 33 did not get an assessment from the ED physician". The complainant also obtained copies of the medical record and highlighted services that were documented that PI # 33 did not receive. "...I feel my car insurance should not have to pay the ED physician for services that were not rendered."

Review of this complaint documentation revealed a letter from EI # 1, Director of Nursing, stating "...It is my understanding that EI # 8, Emergency Room Manager and the ED Medical Director have spoken with you regarding your concerns.....Feel free to contact me in my office...for further concerns." There was no documentation provided to the surveyor detailing conversations between the complainant and EI # 8 and the ED Medical Director. There was no documentation the complaint was investigated or resolved per facility policy.

There was no documentation the grievance was investigated, resolved or that the complainant was notified of the results of the investigation.

An interview was conducted on 4/18/18 at 12:20 PM with EI # 1 and EI # 8, who confirmed the above findings.

Based on review of facility 2017 Quality Assurance/Performance Improvement Plan, review of the facility services, Centers for Medicare and Medicaid (CMS) Hospital Quality Assessment Performance Improvement (QAPI) worksheet and interview, it was determined the facility failed to ensure hospital wide quality data collection was performed, program improvement opportunities were identified and implemented.

This had the potential to affect all patients treated at the facility.

Findings include:

Policy: Performance Improvement Plan
Date Revised: 8/2016

I. Introduction
..."Our focus is on the performance of key functions, the effect of this performance and patient safety. The primary focus is always on appropriate process design and the analysis of our systems and processes....The continuous and systematic monitoring, analyzing and improving performance of clinical outcomes and other processes that impact care and safety are the heart of this plan.
II. Purpose and Scope
The purpose of the plan of improving organizational performance is to provide the framework for ensuring the involvement for the entire organization's performance.
III. Objectives
A. Define a systematic organization-wide framework for the quality improvement process which focuses on the performance of the organization's systems/processes....
E. Ensure coordination of efforts and collaboration among departments, services, patient care and areas and professional teams.
F. improve patient care processes and outcomes through continually monitoring and evaluating the quality and appropriateness of patient care, clinical performance and other patient related processes....

*****
1. An interview was conducted on 4/18/18 at 10:45 AM with Employee Identifier (EI) # 4, Quality Assurance Coordinator to answer questions on the CMS Hospital QAPI worksheet.

During the interview with EI # 4 , the surveyor requested to view data collection, analysis and evaluation of all contracted services and hospital departments.

EI # 4 was unable to provide documentation that all departments, including Anesthesia and Purchasing, and contracted services, submitted 2017 QAPI data or participated in any PI projects. EI # 4 was unable to provide evaluation results for contracted services.

During an interview on 4/18/18 at 10:45 AM, EI # 4 confirmed the facility failed to ensure staff from all departments collected, assessed and analyzed data required to identify key areas for improving patient care.

Based on review of medical records (MR), facility policies and interviews it was determined the nursing staff failed to:

1. Assess pain as indicated by patient need.

2. Reassess pain after giving pain medication(s).

3. Perform wound care under physician orders.

This affected 2 of 10 inpatient records reviewed and did affect Patient Identifier (PI) # 27 and PI # 26, and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: NGEN-DOC-7 Pain Assessment and Management
Date Revised: 2/2018

Purpose:
Atmore Community Hospital supports the patient's right to optimal pain assessment and management.

Policy:
Pain is assessed on admission, during hospitalization (at least every shift), as indicated by patient need, and prior to discharge. It is the responsibility of the clinical staff to assess and periodically reassess the patient for pain and relief from pain

Reassessment and documentation after pain medication is administered should occur within ninety (90) minutes or earlier as patient condition indicates.....

Information obtained may include but is not limited to assessment of the following:
....Pain intensity using a rating scale....The total score ranges from 0-10 points:
Mild 1-3
Moderate 4-6
Severe 7-10....


Policy: NGEN-SKI-2 Pressure Ulcer/Wound/Skin Assessment and Care
Date Revised: 12/2017

Purpose:
To establish guidelines for wound/skin assessment and pressure ulcer prevention and treatment

Policy:
....In the absence of a physician order the nurse may cleanse wound with saline, apply a protective dressing and obtain wound care instructions from physician.


1. Patient Identifier (PI) # 27 was admitted to the swing bed facility on 3/27/18 with diagnosis including Sacral Wound, Decubitus Ulcer of Sacral Region, stage 4.

Review of the 3/27/18, 10:47 AM Nursing Communication Physician's Order revealed order for nurses to pack right chest wound with 2 inch Iodoform gauze (in room) then overlay regular gauze and paper tape on Saturdays and Sundays.

Review of the Medication Administration Report (MAR) dated 4/1/18 thru 4/16/18 revealed the following orders for pain medications available to be administered to the patient:

Tylenol 500mg every 8 hrs as needed for pain started on 3/27/18

Tylenol # 3 300-30 milligrams (mg) every 4 hours (hrs) as needed for pain started on 3/27/18

Robaxin 1,000 mg every 8 hrs as needed for pain started on 3/27/18

Oxycodone 5mg every 4 hrs as needed for moderate pain started on 3/27/18

Morphine 2 mg/ml (milliliter) injection 2 to 4 mg dose every 3 hrs as needed for severe pain started on 3/27/18


Review of the Facility Flowsheets revealed the following dates Dressing/Treatment of the right chest abscess wound was provided by nursing without physician orders:

On Monday 4/2/18 at 4:54 AM, dressing/treatment was documented as Iodoform; 4x4 gauze

On Monday 4/2/18 at 7:00 AM, dressing/treatment was documented as Iodoform; paper tape; 4x4 gauze

On Tuesday 4/3/18 at 7:00 AM, dressing/treatment was documented as Iodoform; paper tape; 4x4 gauze

On Tuesday 4/3/18 at 7:38 PM, dressing/treatment was documented as Iodoform; paper tape; 4x4 gauze

On Thursday 4/5/18 at 7:39 AM, dressing/treatment was documented as Iodoform; paper tape; 4x4 gauze

On Friday 4/6/18 at 7:10 AM, dressing/treatment was documented as Iodoform; paper tape; 4x4 gauze

On Friday 4/6/18 at 7:31 PM, dressing/treatment was documented as Iodoform; paper tape; 4x4 gauze

On Monday 4/9/18 at 7:13 PM, dressing/treatment was documented as Iodoform; paper tape; 4x4 gauze


Review of the Facility Flowsheets dated 3/27/18 thru 4/16/18 and MAR dated 4/1/18 thru 4/16/18 revealed the following pain assessments, reassessments, and pain medication administration:

On 4/2/18 at 10:45 AM patient reported a pain level of a "8" on a 1 to 10 numeric scale.

The next pain assessment was completed on 4/2/18 at 2:53 PM with patient reporting pain at a "9", which was over 4 hrs without severe pain being reassessed or medications administered.


On 4/4/18 at 3:21 PM patient reported pain level of a "6" on a 1 to 10 numeric scale. There was no documentation of pain medication being administered.

The next pain assessment was completed on 4/4/18 at 7:37 PM, which was over 4 hrs without moderate pain being reassessed or medications administered.


On 4/6/18 at 2:49 PM patient reported pain level of a "6" on a 1 to 10 numeric scale. There was no documentation of pain medication being administered.

The next pain assessment was completed on 4/6/18 at 7:31 PM, which was over 4 hrs without moderate pain being reassessed or medications administered.


On 4/9/18 at 9:43 AM patient reported pain level of a "5" on a 1 to 10 numeric scale. Oxycodone 5mg was documented as being administered at 9:43 AM.

The next pain assessment was completed on 4/9/18 at 11:33 AM, patient then reported pain level of a "5" on a 1 to 10 numeric scale. There was no documentation of additional pain medications being administered.

The next pain assessment was completed on 4/9/18 at 7:13 PM, which was over 7 hrs without moderate pain being reassessed.


On 4/13/18 at 3:15 PM patient reported pain level of a "8" on a 1 to 10 numeric scale. There was no documentation of pain medication being administered.

The next pain assessment was completed on 4/13/18 at 7:30 PM, which was over 4 hrs without severe pain being reassessed or medications administered.


In an interview conducted on 4/18/18 at 9:58 AM with Employee Identifier (EI) # 1, Nurse Manager, EI # 3, Accreditation Manager, EI # 6, Occupational Therapy Team Leader, EI # 12, Registered Nurse (RN) Case Manager , and EI # 13, Therapy Director, confirmed the above findings.


2. PI # 26 was admitted to the swing bed facility on 3/30/18 with diagnosis including Cellulitis Bilateral Lower Extremities, Chronic Kidney Disease, Stage III Acute on Chronic

Review of the Medication Administration Report (MAR) dated 4/8/18 thru 4/16/18 revealed the following orders for pain medications available to be administered to the patient:

Ibuprofen 400mg every 6 hrs as needed for pain started on 4/13/18

Norco 5/325 mg 1 to 2 tablets every 4 hrs as needed for moderate pain started on 3/30/18

Morphine 2 mg/ml injection 1 to 2 mg dose every 4 hrs as needed for severe pain started on 3/30/18


Review of the Facility Flowsheets dated 3/30/18 thru 4/17/18 and MAR dated 4/8/18 thru 4/16/18 revealed the following pain assessments, reassessments, and pain medication administration:

On 4/8/18 at 1:10 PM patient reported a pain level of a "8" on a 1 to 10 numeric scale. Norco 5/325 mg was documented as being administered at 1:10 PM

The next pain assessment was completed on 4/8/18 at 7:46 PM, which was over 6 hrs without severe pain being reassessed or effectiveness of Norco assessed.


Review of Physical Therapy Assistant (PTA) note dated 4/13/18 at 10:36 AM revealed documentation of missed PTA visit because patient "states her whole body hurts."

Review of Nursing Flowsheet dated 4/13/18 at 11:30 AM revealed pain screening documentation of "soreness" until pain score area. There was no 1 to 10 numeric pain scale was documented.

There was no documentation of further pain assessment that caused patient to miss therapy visit or documentation of pain medication being administered.

Review of Nursing flowsheet dated 4/16/18 at 8:23 AM revealed documentation that patient reported a pain level of a "10" on a 1 to 10 numeric scale. Norco 5/325 mg was documented as being administered at 8:23 AM

Review of Swing Bed OT (Occupational Therapy) Treatment Flowsheet dated 4/16/18 at 10:29 AM revealed patient refused therapy stating, "I just want to sit here until this pain goes away. I don't feel like doing nothing until I feel better."

Review of PTA note dated 4/16/18 at 11:22 AM revealed documentation that patient refused therapy stating pain was a "10+ and she is not going to exercise anything else." PTA documented that nurse was notified of patient complaint of pain, and will notify MD (Medical Doctor). Review of MR revealed no documentation that MD was notified of pain. There is no documentation of pain medication being administered for patient compliant of pain after nurse was notified.

Review of Physical Therapy Assistant (PTA) note dated 4/16/18 at 2:35 PM revealed documentation that patient refused therapy saying "she is having too much pain to perform exercises this afternoon." PTA documented that nurse was notified of patient complaint of pain. There is no documentation of pain medication being administered for patient compliant of pain after nurse was notified.

Review of Nursing flowsheet and MAR revealed next pain assessment was completed on 4/16/18 at 5:50 PM with patient report of a pain level of a "10." Norco 5/325 mg was documented as being administered at 5:50 PM.

In an interview conducted on 4/18/18 at 9:58 AM with EI # 1, EI # 3, EI # 6, EI # 12, and EI # 13 confirmed the above findings.

Based on review of facility policy, medical records and interviews, it was determined the nursing staff failed to ensure accurate output was recorded for 1 of 1 patient with a Nasogastric tube (NGT). This affected Patient Identifier (PI) # 13 and had the potential to negatively affect all patients admitted to this facility who require an NGT.

Findings include:

Facility Policy: Intake and Output
Effective date: 6/1/15

Intake and Output Monitoring and Documentation

Purpose: To ensure nursing staff apply safe and consistent approach to assessing, monitoring and documenting a patient's intake and output.

Definitions:

... Output includes but is not limited to urinary drainage or voiding occurrence, bowel movements, nasogastric drainage, surgical or wound drains and emesis...

Policy: Intake and output will be monitored throughout the shift and documented at the point of care... A cumulative total is calculated a minimum of every 12 hours. Additionally, intake and output will be assessed, monitored and documented on the following patients:

... B. Patients on medical surgical / telemetry units minimally every twelve hours...

D. Patients with intravenous fluids greater than keep vein open (KVO)...

H. Patients permitted nothing by mouth (NPO)...

*****

1. Patient Identifier (PI) # 13 was admitted to the facility on 4/14/18 with diagnosis including Small Bowel Obstruction.

Review of the History & Physical dated 4/14/18 at 2:50 PM, the Surgeon documented the plan included placing an nasogastric tube (NGT), continue the patient with NPO and intravenous (IV) fluids.

Review of the medical record revealed the Registered Nurse (RN) documented having placed a 16 French (Fr) NGT to the right nostril on 4/14/18 at 3:30 PM and documented as having been removed on 4/17/18 at 9:55 AM.

A review of the medical record revealed the only documentation of output related to the NGT was on 4/15/18 at 6:00 PM, which revealed the NGT was intact with low intermittent suction and brown drainage. There was no documentation of the amount of drainage.

An interview was conducted on 4/18/18 at 9:05 AM with Employee Identifier # 2, Accreditation Specialist, who verified there was no documentation NGT output was measured.

Based on Medication profile review, observation and interview, the hospital failed to assure administration of all patient's ordered medications per physician orders for 1 out of 6 medication passes. This affected an unsampled patient and had the potential to affect all patients served by the hospital.

Findings include:

1.On 4/17/18 at 9:20 AM, the surveyor was on the medical surgical floor to observe the morning (AM) medication pass with Employee Identifier (EI) # 10, Licensed Practical Nurse (LPN) to an unsampled patient in room 227.

The following medications were ordered for 9:00 AM:

Levofloxicin 500 milligram (mg) in 100 cubic centimeters (cc) of Normal Saline (NS) every 24 hours.
Levothyroxine 25 microgram (mcg) daily.
Pantopraole 40 mg daily.
Amitiza 24 mcg 2 times daily.
Mirabegron Tb24 25mg daily with the Dispense Location listed as "Main Pharmacy".

EI # 10 told the patient, "we don't have the Mirabegron here, the MAR (medication administration record) states the medicine is in the Main Pharmacy, which is in Mobile. Do you have anyone that can bring you some from home?" The unsampled patient replied "No, it is for my stomach, I guess I will have to do without it until I go home".

EI # 10 made no attempts to contact the physician or the pharmacist to see if the medication could be obtained.

An interview was conducted on 4/17/18 at 2:30 PM with EI # 1, Director of Nursing, who confirmed the above findings and stated his/her expectations would be for the nurse to notify the pharmacy and the MD and attempt to get the ordered medication or a substitution.

Based on review of medical records, Atmore Community Hospital Medical Staff Bylaws Rules and Regulations, and interview, it was determined the facility failed to:

a. Ensure medical records were complete to include all treatments including wound care interventions.

b. Ensure practitioners complete patients' medical records (MRs) within 30 days of discharge.

This affected 1 of 10 inpatient records reviewed, including Patient Identifier (PI) # 12, and unsampled patients and had the potential to affect all patients who are provided care at this facility.

Findings include:

Subject: Atmore Community Hospital Medical Staff Bylaws Rules And Regulations
Revised Date: 10/2017

"Article 11. Medical Records

A. The attending practitioner shall be responsible for the preparation of a completed and legigle medical record for each patient. Its content shall be pertinent and current...

P. The patient's medical record should be completed at the time of discharge, including progress notes, final diagnosis and dictated clinical resume. When this is not possible because final laboratory or other essential reports have not been recieved at the time of discharge, the patient record will be available in a stated place in the medical records department. The records of discharged patients shall be completed within a period of time that in no event exceeds thirty (30) days following discharge. If a practitioner's records are not completed within this time frame, the president of the medical staff shall notify the practitioner that his privileges to admit patients shall be suspended... and such suspensions of admitting privileges within any such 12-month period shall be sufficient cause for permanent suspension of the privileges of that practitioner.

1. Suspension of hospital admitting privileges shall mean that said practitioner shall not be privileged to admit or treat patients in any manner, including any type of surgery or obstetrical deliveries, except for those patients currently in the hospital and in cases of emergencies..."

******

1. PI # 12 was admitted to the facility on 4/15/18 with diagnoses of Trauma wound, Stab wound to the right upper chest.

Review of the Physician order dated 4/16/18 at 11:08 AM revealed orders for dressing change to the right upper chest as follows: "... Cleanse with Saline, apply Petrolatum (Vaseline) gauze / Xeroform, cover with 4 x 4 (4 by 4) gauze, secure with transparent dressing... Frequency of dressing change: reinforce and change PRN (as needed)..."

Review of the Nursing documentation dated 4/16/18 at 11:29 AM revealed the dressing to the right upper chest was changed at that time. There was no documentation the wound was cleansed with saline prior to applying the Vaseline gauze, 4 x 4s and transparent dressing.

An interview was conducted on 4/18/18 at 9:15 AM with Employee Identifier # 2, Accreditation Specialist, who verified the above findings.



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2. During an observation tour of Medical Record Services on 4/16/18 at 11:00 AM the surveyor observed the following physicians' delinquent charts:

Review of MRs revealed a total of 188 delinquent charts by EI # 17, Director of Surgery, from 6/28/15 through 3/10/18. Further review revealed there was no documentation the President of the medical staff was notified concerning the deliquent charts and the physician continued to treat patients. The facility failed to follow their Medical Staff Bylaws for completing MRs.

Review of MRs revealed a total of 97 delinquent charts by EI # 16, Physician / Emergency Department, from 12/14/15 through 3/18/18. Further review revealed there was no documentation the president of the medical staff was notified concerning the deliquent charts and the physician continued to treat patients. The facility failed to follow their Medical Staff Bylaws for completing MRs.

Review of MRs revealed a total of 80 delinquent charts by EI # 15, Physician, from 3/26/17 through 2/17/18. Further review revealed there was no documentation the president of the medical staff was notified concerning the deliquent charts and the physician continued to treat patients. The facility failed to follow their Medical Staff Bylaws for completing MRs.

An interview was conducted on 4/16/18 at 1:05 PM with EI # 14, Director of Medical Records, who provided the facility's Medical Staff Bylaws for completing MRs and verified the above findings.

Based on review of facility policy and procedure, observations, and interviews, it was determined the staff failed to store medications according to the facility policy. This had the potential to negatively affect all patient's served by this facility.

Findings include:

Subject: Refrigeration, Freezing and Warming
Policy Number: 09-05
Date Reviewed: 5/2017

Policy:

Drugs, biologics and vaccines that require refrigeration, freezing or warming shall be stored in a refrigerator, freezer or warmer that is capable of maintaing the necessary temperature...

Medication refrigerators, freezer limited to storage of medications

The storage of food and other non-medication items in medication storage refrigerators and freezers is prohibited..."

******

An observation tour on 4/17/18 at 9:15 AM on the Post Anesthesia Care Unit revealed a box of AA (double A) Procell batteries and a Flow Cytometry container (used for biopsy lab samples) stored in the medication refrigerator. The staff failed to follow the facility's policy and procedure for storing medications.

An interview was conducted on 4/17/18 at 9:15 AM with Employee Identifier # 18, Operating Room Nurse Manager, who confirmed the above findings.

Based on review of the facility's policy, observations, and interviews it was determined the facility failed to ensure all multi-dose vial medications available for patient use were labeled with an expiration date. This had the potential to negatively affect all patients served by this hospital.

Findings include:

Subject: NGEN-MED-4 Vials: Single Dose/Multi-Dose
Revised Date: 12/2017

"Purpose:

To provide guidelines for the safe injection practices and the preventionof misuse of vials.

Policy:

Staff should follow safe injection and infection control practices as outlined below, in addition to preventing misuse of vials thereby preventing the spread of infection...

Vials: SingleDose/Multi-Dose

Once a multi-dose vial is punctured it should be assigned a "beyond use" (expiration date), which is 28 days or the manufacturer's expiration date..."

******

1. A tour of the Anesthesia Services (Operating Room A) was conducted on 4/17/18 from 10:00 AM until 10:07 AM with Employee Identifier (EI) # 21, Certified Registered Nurse Anesthetist.

The surveyor observed the following multi-dose vials medications were opened and no documented expiration date:

1 - Ketamine Hydrochloride 500 mg (milligram)/ 10 ml (milliliter), 10 ml vial.

1 - Xylocaine (Lidocaine HCL [hydrochloride] injection) 200 mg/20 ml, 20 ml vial.

The staff failed to document an expiration date on opened multi-dose vials medications per policy.

An interview was conducted on 4/17/18 at 10:07 AM with EI # 21 who confirmed the above mentioned findings.

Based on review of facility policy and procedure, observation, and interview, it was determined radiation badges were not monitored according to facility policy. This had the potential to affect all patient's and staff.

Findings include:

Subject: Dosimeter Monitoring and Radiation Protection
Review Date: 12/2017

"Diagnostic/Interventional

Purpose:

Establishment of guidelines for radiation badge placement and wearing.

Policy:

1. Radiologist, technologists, and other personnel occupationally exposed to ionizing ratiation, must wear dosimeters to monitor occupational exposure. Dosimeters are exchanged periodically, and the result of cumulative exposure of each person is available within individual departments.

2. Dosimeters are issued to occupationally exposed personnel. Request for dosimeters are handled through the Radiation Safety Officer.

Procedure:

... 6. Quarterly/Monthly radiation exposure reports on employees are reviewed and maintained infefinitely.

******

During a tour of the Postanesthesia Care Unit on 4/17/18 at 9:15 AM, the surveyor observed Employee Identifier (EI) # 20, Operating Room Registered Nurse, was not wearing a radiation exposure badge. The surveyor aske EI # 20, "Do you have a radiation exposure badge?" EI # 20 stated, "No, I haven't had an exposure badge since I transfered to this location." The surveyor asked EI # 20, "How long have you been at this location?" EI # 20 stated over a year.

The surveyor asked EI # 18, Operating Room Nurse Manager, "Should all surgery personnel wear a radiation exposure badge?" EI # 18 stated, "yes, because staff is exposed to radiation during the use of the C-Arm (x-ray machine)." There was no documentation of EI # 20 quarterly/monthly radiation exposure per facility policy and procedure.

An interview was conducted on 4/17/18 at 11:07 AM with EI # 18 who confirmed the above findings.

Based on review of facility Equipment Management Plan, policies and procedures, observations, and interviews with facility staff it was determined the facility failed to ensure:

a) Equipment was monitored to maintain safety of patients and staff.

b) Supplies and equipment available for patient use were stored per policy, not expired and functional.

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

Findings Include:

Subject: Equipment Management Plan
Review Date: 6/2016

"I. Purpose:

The purpose of the Atmore Community Hospital (ACH)... Medical Equipment Management Plan (MEMP) shall be to facilitate a safe environment for its occupants during the use of powered medical equipment. Medical equipment shall be defined as any patient care equipment which is classified as diagnostic, therapeutic, or analytical.

II. Scope:

... The MEMP shall provide for the following aspects of equipment management:

A. Selection and acquisition of medical equipment.

B. Risk evaluation of powered, medical equipment.

C. Testing of equipment...

VI. Equipment Testing:

... D. Non-Patient Equipment Used Outside Patient-Care Areas

Laboratory instruments are inspected for electrical safety prior to initial use, after repair or modification, and when a problem is suspected...

VIII. Equipment Service By Outside Service Vendors

... B. Department Responsibility

Departments which own medical devices that are serviced by outside vendors shall be responsible for evaluating the devices as well as maintaining current maintenance contracts and service reports.

A. Performance Testing

Each device maintained by outside vendor shall be tested for proper performance and safety at least once per year...

B. Documentation

Departments shall maintain current files on service contracts, service reports, and maintain a current inventory of equipment serviced by outside vendors..."

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Subject: GEN-EP-4 Crash Cart/Defibrillator
Review Date: 3/2018

"Purpose:

Emergency supplies should be available when needed. This policy establishes a procedure for checking emergency equipment and supplies.

Policy:

Crash carts and defibrillator carts should be checked once a day when the department is open...

Procedure:

1. Complete the checklist as indicated...

2. When department is closed, crash cart should be secured in locked area of the department and the checklist should indicate that the department is closed..."

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Subject: PACU (Post Anesthesia Care Unit) -04 Crash Cart Checks
Review Date: 4/2016

Crash carts kept in the PACU should be checked daily and documented in the log kept on the cart.

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Subject: Emergency Equipment Checklist
Revised Date: 8/2003

"Instructions: Emergency carts will be inspected by nursing staff once a day. Nurse signatures on the checklist denote all emergency equipment was inspected according to policy..."

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1. A tour of the Laboratory Services Department was conducted on 4/16/18 at 1:00 PM.

The surveyor observed the following equipment needed a current Preventive Maintenance (PM) documented:

1 - Microscope (serial # 003790) which revealed a documented Preventive Maintenance (PM) service date 1/13/15 and the next due service date was documented 1/2016.

1 - Plasma Thawer Model 301000 which revealed no documented PM.

The surveyor asked Employee Identifier (EI) # 19, Lead Laboratory Technician, "who perform the PM on the laboratory equipment?" EI # 19 stated an outside vendor perform the PM on laboratory equipment. The staff failed to maintain a current PM record for the microscope and the plasma thawer per the Equipment Management Plan.

An interview was conducted on 4/16/18 at 3:43 PM with EI # 19, who confirmed the above findings.

2. A tour of the Surgical Services Department and PACU conducted on 4/17/18 at 9:15 AM.

a. The surveyor observed 1 - Pilling Teleflex Medical (Surgeon's light source) with the last PM date 2/2016. The staff failed to maintain a current PM record for the light source per facility Equipment Management Plan.

b. Review of the Emergency Equipment Checklist log revealed blank spaces on 3/21/18 and 3/23/18. There were documented surgical cases for both days. There was no documentation the staff checked/inspected all emergency equipment per facility policy and procedure and Emergency Equipment Checklist instructions.

An interview was conducted on 4/17/18 at 9:15 AM with EI # 18, Operating Room Nurse Manager, who confirmed the above findings.

3. A tour of the Anesthesia Services (Operating Room B) was conducted on 4/17/18 from 10:08 AM until 10:20 AM with EI # 21, Certified Registered Nurse Anesthetist.

The surveyor observed the following expired supplies on the Anesthesia cart:

2 - Laryngeal Mask airway size 3 (30 - 50 kg [kilogram]), expiration date 3/28/18.

1 - Insyte Autoguard 16 ga (gauge) 1.16 in (inch) needle, expiration date 3/2018.

The staff failed to remove/discard expired supplies.

An interview was conducted on 4/17/18 at 10:20 AM with EI # 21, who confirmed the above findings. The surveyor asked EI # 21 for a policy on expired supplies. EI # 21 stated he/she did not have a policy for expired supplies on Anesthesia cart. EI # 21 also stated the above mentioned supplies should have been discarded/removed from stock before the expiration dates.

Based on review of facility policies, medical records and interviews with facility staff it was determined the facility failed to ensure outpatient therapy initial plan of treatment and therapy re-assessments were signed by the physician. This affected 2 of 3 outpatient therapy records reviewed, including Patient Identifier (PI) # 18, PI # 20 and had the potential to affect all patients admitted for outpatient therapy.

Findings include:

Facility Policy
Subject: Rehab Services - Patient Confidentiality
Date Reviewed: 10/2015, 11/2017

Purpose: To provide framework for appropriate documentation in the Rehab Services department.

Policy: Each chart created in both outpatient and inpatient rehab services, whether PT (Physical Therapy), OT (Occupational Therapy) or SLP (Speech, Language Pathology), should include the following documentation criteria listed below...

Procedure:

To provide guidelines for confidentially and proper documentation.

Each outpatient will have a department folder in EMR (electronic medical record) (ReDoc), which will included initial and subsequent therapy referrals and copies of progress notes and treatment plans...

Proper documentation of communications with the referring physician should be maintained in the patient permanent medical record and should include the physician signature when possible...

Procedure: Initial Evaluation

Overall, Therapy programs involve intense, comprehensive educational and physical therapeutic procedures and exercises and should be justified in terms of their contribution to returning the patient to previous functional status. There should be clearly defined goals, and the patient should have the potential for improvement.

An initial assessment of each patient will be performed by a licensed / registered Therapist to determine and establish a written treatment plan or plan of care based on the prescription of the referring physician and the specific individual needs of the patient as they present... An appropriate plan of care is formulated... within 3 working days for outpatients...

Short-term goals are defined as those that can be achieved within a matter of days or weeks, depending on the patient's current clinical condition. Long-term goals are those that are expected to be achieved as the final functional outcome... Additionally, if short-term goals are not attained within the desired time from the treatment plan must be reassessed by the Therapist to determine if changes or modifications should be made...

The treatment plan or plan of care will identify the specific modalities, procedures or events that will be utilized in order to reduce or eliminate the presenting problems and facilitate achieving the long-term functional goals in the treatment plan...

Summary Progress Report (Reassessment) is designed to exhibit the patient's progress and overall response to the initial treatment plan and justifies the continuance of the established treatment plan or the necessity for a change in the initial treatment plan...

Any changes in the plan of care or goals will be made by the responsible therapist based on these objective findings and in consideration of any necessary medical directions or prior authorization requirements.

Any changes required in a patient's treatment program will be followed with correspondence to the referring practitioner notifying him of the changes. The referring physician must sign the Summary Progress Report (Reassessment) so that there is evidence that the physician was informed of the changes...

*****

1. PI # 18 was admitted to the facility on 3/19/18 with the diagnoses including Radiculopathy, lumbar region, Low back pain, Pain in left leg and Difficulty in walking for outpatient PT.

Review of the Plan of Care dated 3/19/18 was signed by the PT on 3/19/18. Review of the fax conformation sheet dated 3/20/18 at 9:12 AM revealed the patient's name and, "... Please have the physician sign the attached Plan of Care and fax back to (phone number)..." There was no documentation the physician signed the Plan of Care dated 3/19/18.

An interview was conducted on 4/17/18 at 1:34 PM with Employee Identifier (EI) # 6, Occupational Therapist Team Leader, who verified the above findings.

2. PI # 20 was admitted to the facility on 10/12/17 with the diagnosis of Unspecified lack of expected normal physiological development in childhood for outpatient SLP services.

Review of the Progress Reports dated 12/28/17 and 3/22/18 revealed Interventions / Plans and Goals for the patient and there was no documentation of the physician's signature. Review of the fax conformation sheets dated 12/28/17 and 3/22/18 revealed no documentation a physician's signature was requested.

An interview was conducted on 4/17/18 at 1:34 PM with EI # 6, who verified the above findings.

Based on review of contracts, policy, and interview with administrative staff it was determined the facility failed to maintain a dentist on contract for provision of routine and emergency dental services to meet the needs of each swing bed resident which has the potential to impact all swing bed residents.

Findings include:

Subject: NGEN-SWB-15 Dental Services

Policy:
Given the short stay of the program, it is anticipated that the patient will be obtaining routine dental care after discharge but the patient will be assisted in obtaining emergency dental care.


The surveyor requested a copy of the dental contract from hospital staff.

The facility had no dental contract to review.

An interview with Employee Identifier # 1, Nurse Manager, on 4/18/18 at 7:35 AM was conducted. EI #1 verbalized that the facility had sent a letter to a local dentist but he/she decided not to contract with facility. The Surveyor asked for a copy of the letter to the local dentist and was provided letter dated 9-19-16. Surveyor then asked EI #1 if there had been any more letters to attempt to contract with dentist. EI #1 denied any other letters to attempt dental contracts being done.

In an interview conducted on 4/18/18 at 9:58 AM with Employee Identifier (EI) # 1, EI # 3, Accreditation Manager, EI # 6, Occupational Therapy Team Leader, EI # 12, Registered Nurse Case Manager, and EI # 13, Therapy Director, confirmed the above findings.