HospitalInspections.org

Based on observations and interviews, it was determined the facility failed to ensure the patients were in a safe environment free of ligature risks. This had the potential to negatively affect all patients being served on the Geriatric Behavioral Health unit.

Findings include:

During an initial tour conducted on 3/20/18 at 9:20 AM, the surveyor noted the following on the Geriatric Behavioral unit:

The surveyor observed in rooms BH21 to room BH25, the headboards and footboards of all beds were not 1 continuous piece of material but instead had 2 rectangular openings, approximately 5 inches by 3.5 inches in area, cut into the hard plastic material of the headboard and the footboard, which is a ligature risk.

Further observation of the rooms also revealed 1 wooden bedside table next to each bed, with a wooden rail around the top of the table, that was not flushed to the base of the table resulting in a space between the two parts. The surveyor was able to put 2 fingers between the top of the bedside table and the base of the wooden railing, which is a ligature risk.

The beds were electronic with exposed cords which were greater than 18 inches in length, which is a ligature risk.

An interview was conducted on 3/20/18 at 3:00 PM with Employee Identifier (EI) # 4, Nurse Manager Behavioral Health, who confirmed the above findings.

Based on review of facility policy and procedure, observation, and interview with staff, it was determined the facility failed to ensure the confidentiality of patient medical record (MR) for 2 of 2 unsampled patient's currently admitted to the Behavioral Health units of the hospital. This had the potential to negatively affect all patients served by the Behavioral Health units of the hospital.

Findings include:

Policy: Policies and Procedures Regarding Privacy, Security, And Confidentiality HIPPA (Health Insurance Portability and Accountability Act)
Revised Date: 1/2004

HIPPA Confidentiality Policy: "...The problem of maintaining the confidentiality of patients' records is one that has implications for management, legal advisors, and , indeed, all THA (Tombigbee Healthcare Authority) employees. Information of a confidential nature must not be inadvertently or purposefully disclosed without the consent of the patient or a logical and evidently supportable "qualified privilege". Per organizational policy and values, THA...shall consistently strive to maintain the confidentiality of patient information on a "reasonable person basis....

...Alabama regulatory law requires that hospitals consider all patient information contained in the record as confidential....

2. Access...
c. Health records shall be available of ruse within the facility of redirect patient care only by authorized personnel as specified by the chief executive officer, and as documented in the administrative and divisional policy manuals....
n. Any information contained in the health record will not be revealed to any employee of the THA who has not been involved in the care of the patient without written authorization from the patient or guardian or upon approval of the CEO (Chief Executive Officer)/Administrator."

D. 1. Psychotherapy Notes - Psychotherapy notes are those "notes recorded ( in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversations during a private counseling session or group...that are separate from the rest of the individual's medical record." Except for use by their author for treatment purposes,...disclosure of psychotherapy notes...will require patient authorization."

*****
1. On 3/20/18 at 3:00 PM, the surveyor asked Employee Identifier (EI) # 4, Director of Geriatric Behavioral Health unit and the Adult Psychiatric Inpatient unit, if the electronic medical records (EMR) were secure and asked who can access the EMR (Electronic medical Records) of the patients on his/her units. EI # 4 stated all staff in the hospital could access the medical records and there was no security to prevent access to psychiatric care records.

On 3/22/18 at 8:30 AM, the surveyor asked EI # 10, Director of Medical Records, what security was in place to protect the confidentiality of the EMR for the patients on the Geriatric Behavioral Health unit and the Adult Psych units. He/ she stated there is a lower case "c" in front of the patients name on the menu which indicates to the user the patient is confidential. He stated there is also a warning screen that states the "visit is confidential" but allows the user to choose "Yes" and the complete psychiatric record can be accessed.

EI # 10 informed the surveyor the director of IT (Information Technology) assigned security rights to the staff on new-hire and has the capability to limit some staff from having access to the psychiatric medical records. EI # 10 stated the facility has failed to limit the access to the psychiatric EMRs.

EI # 10 accompanied the surveyor to the medical surgical floor. EI # 10 requested an RN (Registered Nurse) on 3rd floor Medical Floor, who was not involved in the care of any psychiatric patients, to type in the patient identification number of a psychiatric patient. The RN was instructed by EI # 10 to choose "Yes" on the warning screen, and opened the medical record. The entire medical record of the psychiatric patient was able to be accessed by this employee who was not involved in the care of this psychiatric patient.

The surveyor asked EI # 10 if random security audits are performed to monitor whether staff are accessing the confidential EMR's. EI # 10 was not aware of any monitoring being performed by the facility staff.

The surveyor asked EI # 5, Director of Professional Services, if random security audits are performed to see if confidential records are being viewed by staff not providing care to the psychiatric patients. EI # 5 was not aware of any audits being performed.

The surveyor also observed in the nurses station that housed the hard copy of the MR for the Adult Psychiatric unit to be shared by the nurses from the Adult Psychiatric unit as well as the nurses and staff from the Self Recovery unit. The medical records were in view of all staff. The doors to the nurses station were not locked at all times.

In an interview conducted on 3/22/18 at 4:20 PM with EI # 5, who confirmed the above mentioned findings.

Based on review of the 2018 Quality Improvement Plan, Post Anesthesia Evaluation and interviews, it was determined the hospital failed to ensure:

1. Each department of the hospital has an active and ongoing quality program for patient care.

2. Implement corrective actions focusing on performance improvement and quality in patient care.

This deficient practice could have a negative affect on ptients admitted to the facility.

Findings include:

2018 Performance Improvement Plan
Revised date 1/30/18

Purpose

This Performance Improvement Plan promotes the mission of Bryan W. Whifield Memorial Hospital by establishing a formal, organization-wide system to monitor and constinuosly improve patient outcomes and services.

Responsibilities

The Director of Professional Standards is responsible for:
Overseeing an ongoing, systematic process to track the evaluation of quality and appropriateness of care.
Assuring the integration of information among the medical, professional and non-clinical staffs inluding monioring and evaluation of Risk Management and Infection .

Department Managers are responsible for:
Assuring Performance Improvement (PI) activities are arried out and appropriately documented.

Submitting required reports of PI activities as appropriate.

PI Commitee Functions include:

Provide oversight for development, review, and evaluation of PI activities.


Review of the information gathered from the Post Anesthesia Evaluation the CRNA (Certified Registered Nurse Anesthesia) revealed the following: patient's vital statistics, whether the patient met the criteria for ASA (Anaesthetic Risk Assessment), CRNA Attestation, Surgical Procesure, Anesthesia Start and Stop Time.

An interview was conducted on 3/20/18 at 3:30 PM with Employee Identifier (EI) # 9, CRNA to discuss quality improvement activities for the department. EI # 9 stated that she/ he does not have any quality indicators that is currently being reviewed or submitted to the Srgery Committee or to the hospital Quality team. She/ he does, however, collect post anesthesia information on surgery patient but does not submit to the hospital wide Quality Team.

Based on the review of the facility's 2018 Performance Improvement Plan and interview, it was determined the facility failed to ensure the Performance Improvement Committee was hospital-wide. This had the potential to affect all patients served by this facility.

Findings include:


Facility's 2018 Performance Improvement Plan

Purpose:

This Performance Improvement (PI) Program promotes the mission of Bryan W. Whitfield Memorial Hospital by establishing a formal, organization-wide system to monitor and continuously improve patient outcomes and services.

The purpose of the PI Plan is to provide a written guideline for the Performance Improvement Program. This plan will be used by each employee of the organization to continually monitor and improve the processes they perform...

Objectives:

The objectives of the PI Plan are as follows:

6. To define the integration of care services by requiring each department to identify their scope of service, to include what service they provide, to whom, how, and how others interact with them in providing the service.

Administration:

Bryan W. Whitfield Memorial Hospital's administrative leaders are responsible for setting expectations, developing plans, and implementing procedures to assess and improve the quality of the organization's governance, management, clinical, and support process. Leadership shall fulfill these responsibilities by:

Setting priorities for the organization- wide performance improvement activities that are designed to improve patient outcomes...

Review of the committee meeting minutes for 2017/ 2018 committee meeting minutes revealed no documentation of the adult Alcohol and/ or Drug Abuse Unit were included in the planning. The surveyor asked Employee Identifier (EI) # 5, Director of Professional Standards if the adult unit was included in and the response was no.

An interview was conducted with EI # 5 on 3/22/18 at 1:25 PM who verified the above findings.

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

1. Perform wound care as ordered and ensure complete wound care orders were obtained.

2. Measure wounds and document wound assessments per policy.

3. Followed physician orders for insulin administration and performing blood sugars.

4. Document the patient's acceptable level of pain

5. Document physician notification of therapeutic effectiveness of pain medication.

This affected 3 of 4 patient records reviewed with wound (s) and did affect MR # 34, # 33 and # 10, and had the potential to negatively affect all patients served by the facility.

Findings include:

Facility policy: Wound Care Management
Revised Date: 11/16

Policy:
To provide a comprehensive wound management program to promote the preventative and supportive care to patients who are at risk for skin breakdown. Every effort shall be made to provide effective preventative skin care, beginning at admission and throughout the patient's stay.

A commitment to the wound management program is demonstrated by implementation of processes founded on accepted standards of practice, ...

Admission wound assessment:
When any patient is admitted into the hospital nursing service will perform a complete skin and wound assessment. Dressings will be removed, wounds measured and documented.

Skilled PT (Physical Therapy) wounds:
1. Complex wounds (stage 3-4) that need special care to manage, selective sharp debridement or complex compression wrapping...
3. Wounds that have been cared for by nursing for greater than 3 days that has significant increase in bread down despite wound care, off-loading and moisture control...
6. Wounds that are necrotic or have undermining or tunneling greater that 10 centimeters (cm) that require skilled PT care.

Prevention:..

11. Report and chart the first evidence of pressure sores. Documentation within the EMR (Electronic Medical Record) should include; staging, drainage (color and amount, if present), areas involved and interventions performed..."

***
Facility policy: Pain Management
Revised Date: 6/10

"Purpose:

It is the policy of Bryan W. Whitfield Memorial Hospital to respect and support the patient's right to optimal pain assessment and management...

Pain Reassessment:

The nurse will reassess pain within one hour following the administration of a pain medication or implementation of other pain control mechanisms to determine its effectiveness...

Practice Guidelines:

... The following guidelines will be observed for assessment and usage of pain intensity scales...

Adults through geriatrics including anesthesia patient or those with other limitations:
... Behavior scale or Faces Pain scales (0-10 least pain to worst pain)...

Should the patient complain, or exhibit signs and symptoms of pain between the medication administration times (as prescribed by the physician), the nurse will contact the physician for further orders...

Patient Education:

... Patients will be taught that pain management is part of their treatment. The patient/family/significant other will receive education provided by the staff regarding management of the patient's pain. Education may include, but is not limited to:

... Determination of the patient's acceptable level of pain..."

***

1. MR # 34 was admitted to the facility on 3/15/18 with diagnoses including Cellulitis Right Lower Extremity, Diabetes, Diastolic Heart Dysfunction, Chronic Renal Failure and High Blood Pressure.

Review of the 3/15/18 Emergency Room (ER) physician's note revealed documentation of 2 ulcers # 1- Large Diabetic Ulcers on front of right lower leg with the measurements of 14 cm. (centimeters) by (X) 8 cm. with exudate and # 2 was a "very" small ulcer on top of right foot, measuring 1 cm. X 2 cm.

Review of the 3/15/18 Physician's Verbal order at 4:56 PM revealed, "clean wound to right lower extremities with Karaklenz. Cover with Xeroform gauze and cover with 4 X 4 and abdominal (ABD) pad and wrap with kling."

Review of the 3/15/18 5:34 PM revealed nursing documentation of "wound 5 1/2 inch by 3 1/2 inch wound to right lateral leg and open wound noted to coccyx area. Wound to right leg covered with Adaptic and Kerlex."

The nurse failed to perform wound care as ordered by the physician and notify the physician of the wound to the coccyx or measure the wound.

Review of the 3/18/18 Physician's Progress Note revealed the patient had Methicillin Resistant Staph Aureus and Pseudomonas Aeruginosa was cultured from the right lower leg wound.

Review of the 3/19/18 nursing discharge instructions revealed the patient was taught about Cellulitis. There was no documentation the patient's family was provided education on performing wound care, how to dispose of dressings with known wound infections. Further review revealed no documentation the family demonstrated how to perform wound care.

In an interview conducted on 3/22/18 at 1:00 PM with EI (Employee Identifier) # 17, Nurse Manager, confirmed the above findings.

2. MR # 33 was admitted to the facility on 2/23/18 with diagnoses including Chronic Wound to Right Thigh Possible Spider Bite, Diabetes Mellitus, and Hypertension.

Review of the 2/24/18 Physician's Verbal Order revealed wound care twice daily. " First dressing (drsg) change was to apply Santyl ointment to inner wound and pack with dry Kerlex drsg/ and cover with 4 x 4 gauze dressing. Second drsg change with was to use Dakin's Solution. Soak Kerlix with solution and pack.

The surveyor asked EI # 17 was the order for wound care complete and included what the nurse was to used to clean the wound with and the strength of the Dakin's Solution. The response was " that was what was in the physician orders". EI # 17 failed to clarify wound orders with the physician.

Review of the 2/24/18 nursing note for 8:00 PM revealed the documentation Normal Saline (NS) was used for wound care and there was no physician order received. The nurse failed to follow physician orders for wound care.

Review of the 2/28/18 nursing note for 8:00 PM revealed documentation of the presence of tunneling of the wound. There was no documentation of how much tunneling or the physician was notified of the tunneling.

Review of the 2/24/18 10:44 PM Physician's Order revealed the following sliding scale orders:
Blood Sugar (BS) 201- 250 4 Units (U) subcutaneous (SQ) with meal.
BS 251- 300 6 U SQ with meal.
BS 301- 350 8 U SQ with meal.
BS 351- 400 10 U SQ with meal.
BS > (greater than) 400 12 U SQ with meal.

Review of the MR revealed the following documentation for the treatments of BS:

2/23/18 at 7:54 PM, BS- 553 and at 8:56 PM, 10 U of insulin was administered and not 12 Units as ordered.

2/24/18 at 7:20 AM, BS, of 224 there was no documentation insulin was administered according to the physician's orders.

2/24/18 at 4:43 PM, BS of 210 there was no documentation insulin was administered according to the physician's orders.

2/25/18 at 10:44 AM, BS 415 and the patient was treated with 12 units at 1:47 PM. There was no documentation of the reason for the late administration of insulin. There was a time lapse of 4 hours and 3 minutes. The nurse failed to notify the physician.

2/25/18 at 4:29 PM, BS of 365 there was no documentation insulin was administered as ordered.

2/27/18 at 8:02 AM, BS of 202 there was no documentation insulin was administered as ordered.

2/28/18 at 11:55 AM, BS of 233 there was no documentation insulin was administered as ordered.

2/28/18 at 4:29 PM, BS of 230 there was no documentation insulin was administered as ordered.

3/1/18 at 11:25 AM, BS of 249 there was no documentation insulin was administered as ordered.

In an interview conducted on 3/22/18 at 9:40 AM with EI # 17 confirmed the above findings.



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3. MR # 10 was admitted to the facility on 3/18/18 with diagnosis including Dehydration with Hypercalcemia, Immobility, and Questionable Deep Vein Thrombus.

Review of the Skilled Nurse (SN) note (Pain Assessment) dated 3/20/18 at 9:10 AM revealed documentation of the patient's reported pain score was 10. EI # 24, Registered Nurse, documented pain medication given (Norco 10).

EI # 24 documented the patient's was re-assessment ad the pain score was an 8 at 9:40 AM. There was no documentation of the therapeutic effectiveness of the Norco. EI # 24 fail to document the patient's acceptable level of pain per facility policy.

An interview was conducted on 3/22/18 at 1:40 PM with EI # 17, Nurse Manager, Medical Intensive Care Unit / Medical-Surgical Unit, who confirmed the above findings.

Based on review of personnel files, job descriptions and interview, it was determined the facility failed to ensure staff were equipped to respond to emergencies within the department by allowing Radiology staff to have expired Cardiopulmonary Resuscitation (CPR) certification. This could negatively affect all patients receiving Radiology and Nuclear Medicine services in the facility.

Findings include:

Review of job descriptions on 3/22/18 at 11:00 AM for Radiology technicians and the Radiology Director, revealed the employee will be CPR certified within 3 months of hire.

Review of the personnel files of Radiology and Nuclear Medicine staff and the Director of Radiology, revealed CPR certifications were expired for 3 of 3 employees.

An interview was conducted on 3/21/18 at 10:00 AM with EI # 21, Director of Radiology and Nuclear Medicine, who confirmed the above and stated he/she was aware of the CPR certifications being expired but has not scheduled CPR classes for certification.

Based on United States Health Public Food Code 2009 regulations, facility policies, observations and interview, it was determined the hospital failed to ensure:

a) Food was stored in a safe and sanitary manner.

b) Expired foods, paternal nutrition, and supplies were available for patient use.

c) The dishwashing machine temperature was checked for each use.

d) Staff washed hands before applying gloves and wore hairnets in the kitchen.

e) Infection control policy and procedures were in place for laundering aprons/ mop heads.

f) Dietary policy and procedures were reviewed annually.

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...


Facility Policy: Leftover Utilization
Policy Number: 63.06
Effective Date: 6/02

Policy:

Leftovers are minimized through menu planning... Leftovers are used within 48 hours or by the next meal whenever possible...

Facility Policy: Food Supply and Storage
Policy Number: 62.01
Effective Date: 6/02

Policy: All food, non-food items, and supplies used in food preparation shall be stored in such a manner as to maintain the wholesomeness of the food for human consumption.

Dry Storage...
Remove from storage any items for which the expiration date has expired...

Refrigerated Storage:...
Date and rotate items; first in, first out.
Discard leftovers not utilized within 48 hours.
Unused portions: cover, label, date and store above raw foods. Store cooked meats above raw meat.
Thaw meats in the cooler.

Frozen: ...
Date and rotate items..."

Facility Policy: Mandatory Work Habits
Policy Number: 41.03
Revised Date: 6/02

As a matter of policy there is certain work habits mandatory of any person working food service or production...

2. Each person shall consistently observe the following practices:
A. Wash hands with soap, warm water, and nail brush before starting work, after handling soiled articles...
J. Hairnets or other hair restraints must be worn at all times in the food service areas."

Facility Policy: Dishmachine Temperatures
Revised Date: 6/02

Procedure:

"1. During each period of use, records wash and final rinse temperatures on the Dishmachine Temperature Record Form."

A tour of the Dietary Department was conducted on 3/20/18 at 9:55 AM with the Employee Identifier (EI) # 15, Dietary Manager and EI # 14, District Resource Manager. The surveyor observed the following:

In the freezer:

2 plastic Ziploc bags of pork chops (identified by EI 14)- no label of contents or date.
A pan of french onion soup with plastic wrap cover (no date on the label).
A pan of turkey and dressing with a hard plastic cover labeled 3/16/18.
A pan of grit casserole with plastic wrap cover labeled 3/16/18.
A pan of taco meat with plastic wrap cover labeled 3/16/18.
An opened plastic bag of chicken fingers with no label.

In the cooler:

3 dietary employees come out of the cooler without hairnets.
A pan of beef brisket labeled 3/9/18 and discard by 3/17/18.
A pan of green beans with no label.
A pan of red beans and rice labeled 3/12/18 and no discard date.
A pan of sweet potatoes labeled 3/15/18 and discard 3/22/18.
A pan of vegetable soup labeled 3/13/18 and no discard date.
A pan of cooked rice labeled 3/16/18 and the discard date of 3/18/18.
A pan of gravy labeled 3/16/18 and no discard date.
A gallon size plastic container of mayonnaise with no open date.
A plastic Ziploc bag of lunch meat labeled 3/16/18.
A 16 oz container of heavy whipping cream use by 2/8/18.

The following 5 pound (lb) plastic containers were open and in the cooler:

Chicken salad labeled opened 12/15/17 and the use by date of 2/18/18.
Pimento cheese salad opened 12/15/17 and the use by date of 2/18/18.
Pasta salad with feta cheese labeled opened 3/4/18, and the use by date 3/7/18.
Tropical fruit salad labeled opened 3/14/18, the use by date was 1/31/18.
Tuna salad labeled 3/13/18/ discard on 3/18/18.
California pasta salad with the use by date of 3/15/18.
Coleslaw no open date
Potato salad no open date.

In the "Use Today" refrigerator:

A tray of green jello covered with plastic wrap and not labeled- the surveyor asked EI # 15, when was this prepared. The response was Friday or Saturday.
A plastic wrap covered french toast and pancakes with no label.

In an interview conducted with EI # 14 at 11:55 AM who verified the food in the cooler should be labeled and dated.

During the observation of dishwashing conducted on 3/20/18 at 12:55 PM the surveyor noted a washing machine and dryer located on entry to the dish washing area. Lying on top of a yellow metal cabinet were red, white, and black aprons along with 3 dry mop heads.

The surveyor asked EI # 15 who does the laundry and were the above mentioned items clean or dirty. EI # 15 response was the person that comes in at 10:30 AM does the laundry and was not sure if they above mentioned items were clean or dirty.

The surveyor asked requested from EI # 14, District Resource Manager, for the policy and procedure for dietary staff laundering aprons and mop heads, that included disinfection of the washing machine after washing mop heads and before washing aprons; identification of clean versus dirty aprons/ mop heads. EI # 14, stated there was no policy for laundering in the dietary department.

In an interview conducted on 3/22/18 at 10:30 AM with EI # 14, confirmed the above findings.

Review of the Dishmachine Temperature Records from 1/11/18 to 3/20/18 revealed no documentation the temperatures were checked as follows:

1/11/18 - Midday Readings
1/29/18 - Midday Readings
2/16/18, 2/23/18, 2/27/18, 2/28/18, 3/6/18, 3/11/18, 3/17/18, and 3/18/18 -Evening readings.

Review of the Daily Temperature Logs for Walk-In Cooler # 1, Walk-In Cooler # 2, Walk-In Freezer for 3/4/18 to 3/18/18 revealed no documentation the temperatures were checked at the following times:

3/4/18 AM, 3/6/18 PM, 3/11/18 PM, 3/16/18 AM, 3/17/18 PM and 3/18/18 PM.

Review of the Hot Food Production & Cooling Temperature Log for January, February and March revealed no documentation a weekly review was conducted.

In an interview conducted on 3/22/18 at 10:30 AM with EI # 14, confirmed the staff failed to complete logs.

On 3/22/18 at 10:00 AM the surveyor conducted a follow up tour of the dietary department with EI # 15 and found the following:

The following parental nutrition and supplies were expired:

28- packages (pkgs) Arginaid Powder expired 11/13/17.
22- pkgs BeneProtein Instant Powder expired 2/2/18.
22- Osmolite 1.2 calorie (cal) 240 milliters (ml) cans expired 1/1/18.
23- Jevity 1.2 cal 240 ml can expired 2/1/18.
2- Compat Enteral Delivery tubing expired 5/16.

In the cooler:

The following large pans covered with plastic wrap and labeled 3/21/18 and discard on 3/27/18 (6 days):

Chicken salad
Beans
Baked Chicken
Macaroni and cheese

A pan of cheese sauce was labeled 3/21/18 -discard 3/28/18 (7 days)
A pan of apples was labeled 3/20/18 -discard 3/25/18 (5 days)

2 pans of raw hamburger patties covered with plastic wrap and were labeled 3/21/18 - discard 3/24/18 (3 days).

The surveyor asked EI # 15 if the frozen hamburger patties were to remain frozen until cooked. EI # 15 was unsure.

The hamburger patties were unthawed on the top rack of the cooler and underneath the raw unthawed hamburger patties were 2 large pans of beef stew covered with aluminum foil.

A plastic bag of chicken fajita seasoned strips was open unthawed and not labeled with open date. Review of the cooking instructions on the bag revealed, "Keep frozen until cooking"

EI # 14 confirmed the frozen meat was thawed inappropriately and raw meat was placed above other cooked food.

In the freezer:
A pan of cooked pulled pork covered with plastic wrap labeled with 1/26/18. The surveyor asked if this had been cooked and re-frozen. EI # 15 provided no response.

An interview was conducted with EI # 14 on 3/22/18 at 10:30 AM, who verified the above findings.

Based on review of facility policy and procedure, observation, and staff interviews, it was determined the facility failed to ensure that all patient's food was stored inside of the patients' refrigerator. This had the potential to negatively affect all patients admitted to the facility.

Findings include:

Policy and Procedure: Committee/Department Food Services
Between Meal Nourishments
Date: 7/2000
"Policy Number: 52.01 / Floor Supplied Patient Nourishments Introduction

It is the policy of the Dietary department of Bryan W. Whitfield Memorial Hospital to provide an assortment of nutritional snacks, juices, to each patient care areas on each floor. Snacks, supplements, etc. (et cetera) are requested by the patient are supplied from the floor. Each nursing station has a patient refrigerator used for the storage of juice, milk and popsicles to be available for the exclusive use of patients...

8. The patient refrigerator is for the exclusive use of patient food and beverages, Food not supplied by the dietary staff will not be placed in the refrigerator. If a patient brings food from outside the hospital or requests to store uneaten parts of his meal from his meal tray in the refrigerator, this request will be denied. No food belonging to hospital staff will be stored in the refrigerator..."

******

1. An observational tour of the MICU (Medical Intensive Care Unit) was conducted on 3/20/18 at 10:20 AM with Employee Identifier (EI) # 17, Nurse Manager - MICU / Medical-Surgical and EI # 24, Registered Nurse (RN).

The surveyor observed 6 (4 - ounce) ice cream cups stored in the staff freezer. The surveyor asked EI # 17, "Is that ice cream for your patient's?" EI # 17 stated, "Yes, we store it in the staff refrigerator because we don't have a refrigerator with a freezer for the patients." The staff failed to store patients' food per facility policy and procedure.

An interview was conducted on 3/22/18 at 1:06 PM with EI # 5, Director of Professional Standards, who confirmed the above 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 negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations

Based on observations, interview and facility protocol, the facility failed to maintain a clean and safe environment. In addition, the facility failed to assure all patient- use equipment and supplies were safe and had been checked for scheduled maintenance.

This affected the Operating Room, Recovery Room, Endoscopy Room, Respiratory Services, Medical- Surgical Services, Emergency Department and other areas of the hospital.

Findings includes:

MCN (Maintenance Change Notice) # 1008
Subject: Equipment Management Plan

Policy
Bryan W. Whitfield Memorial Hospital's Equipment Management Program's scope is to maintain a medical equipment program which promotes safe and effective us of medical equipment. ...

Assessing and Minimizing Clinical and Physical Risks of equipment Through Inspection, Testing and Maintenance.

Preventive maintenance will be completed on all equipment in the program.

***
MCN # 1009
Subject: Equipment Management Program

Policy
... All mechanical and/ or electric devices use in patient care or diagnosis will be part of the program.

Procedure:

Maintenance Requirements: This maintenance requirements will be based on the equipment Management Inventory Code System (EMC).

MCN # 1010

Equipment Management Code System (EMC)

The following is a sample formula to meet requirements of evaluating equipment to include Preventive Maintenance (PM) program.

EMC is assigned according to the following formula:
(EMC= Function + Risk + Maintenance Requirement

6 to 15 - Minimum of 1 PM per year ( usually provided by the equipment manufacturer=maturer.

2. Surgical and Special Care Unit - 9

*****

Chapter F: Storage of Pharmaceuticals and Supplies
Last Revised: September 18, 2011

All medications are to be stored in an environment that is suitable for the given chemical an stability properties of the drug and is to be stored in a manner that enhances safety in dispensing, administering, and distribution as well as protects the potency of the medication.

5) Outdated drugs are removed monthly from the current stock and returned, as far as feasible to the original vendor or manufacturer.


A tour of the Operating Room (OR), Recovery Room (RR), Endoscopy Room (Endo Room) and Central Sterile (CS) areas conducted on 3/20/18 at 10:00 AM with Employee Identifier (EI) # 2, Operating Room (OR) Nurse Manager revealed the following expired preventive maintenance (PM):

OR # 2
1. Sabre 200 (Con Med Company) Bovie - 2017- (no month or date performed or due documented).
2. Arthrex (Continuous Wave III Arthroscopy Pump) - 2017 (no month date performed or due documented).

Endo Room
1. System 24500 - dated 2017 --no month or date performed or due date documented).
2. Endoscopy Gators - dated 2017- no month or date performed or due date documented.
3. ERB ICC 200 - dated 2017 - no month or date performed or due date documented
4. Ultraview SL - dated 2017 - no month or date performed or due date documented.
5. Olympus Exera II - CV 180 x 2 - dated 217 - no month or date performed or due date documented.
6. Olympus OEP 4 and HDT V - dated 2017 -no month or date performed or due date documented.
7. Olympus UHI 3 - dated 2017- no month of date performed or due date documented.

Review of the preventive Maintenance Check List conducted on 3/21/18 at 4:00 PM revealed equipment identified during the tour were last inspected and labeled 2/2017 by the Maintenance Department staff.

An interview with Employee Identifier (EI) # 2, OR Nurse Manager conducted on 3/20/18 at 10:00 AM, EI # 2 verified the above mentioned findings.



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A tour of the respiratory department was conducted on 3/21/18 at 11:05 AM with EI # 8, Respiratory Therapist, revealed the following expired supplies and equipment with no current PM stickers.

1- Ventilator 760- will the label did not pass inspection 1/19/13 and no further documentation.
1- Bear Ventilator CPAP machine last inspection 2008.
1- CPAP machine with no inspection sticker.
10- Sterile water containers 1650 milliliter (ml) expired 4/03.
16- Sterile water containers 1650 ml expired 11/04.
6- Nebulizer adapters expired 11/16.
1- Nebulizer adapter expired 11/17.
2- Nebulizer adapters expired 4/17.

In an interview conducted on 3/22/18 at 8:50 AM with EI # 21, Respiratory Director, confirmed the above findings.

On 3/20/18 at 2:42 PM the surveyor conducted a tour of the medical floor with EI # 11, Registered Nurse, and the following observations were made:

On the crash cart:

4- packages (pkgs) of water based lubricant expired 2/15.
1- tubing for suction machine expired 10/15/16.
1- sharps container attached to the crash cart was over-filled.

In the medication room:

3- pkgs of Microspore extension sets expired 9/17.
2- pkgs of extension set tubing were opened and lying on the shelf.
2- pkgs of Chlorprep solution expired 11/17.
1- eye patch expired 3/16.

In an interview conducted on 3/20/18 at 3:15 PM with EI # 5, Director of Professional Services, confirmed the above findings.

The suction machines last PM was conducted 4/16.



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During a tour of the MICU (Medical Intensive Care Unit) area on 3/20/18 at 10:20 AM the crash cart on the MICU area was checked. The following expired supplies were found:

Crash Cart:
1 - Arterial Blood Gas syringe expired 12/2017
1 - Medline Suction Tubing expired 3/8/2017

Medicine Room:
2 - Bardex Foley Catheter 16 FR. (French) 5 cc (Cubic Centimeter) ribbed balloon expired 12/2017

Supply Room:
1 - Thoracic Trocar Catheter 28 FR. soft expired 5/2015
2 - BD (Becton Dickinson) Vacutainer green top expired 2/28/18
1 - Evacuated Container 1000 ml (milliters) bottle expired 5/2011

An interview was conducted on 3/20/18 at 11:23 AM with EI # 1, Chief Nursing Officer, who confirmed the above findings.

During a tour of the Emergency Department (ED) area on 3/21/18 from 2:39 PM - 3:48 PM the following expired supplies were found:

ED Trauma Room:

3 - Lubricating Jelly packets expired 2/2017
1- Surgilube (Surgical Lubricant Sterile Bacteriostatic, 4.25 ounce tube) expired 4/2017
1 - Ultrasite IV (Intravenous) set for Outlook Safety Infusion System expired 1/2018
1 - Normal Saline IV flush syringe (10 ml fill in 12 ml syringe) expired 2/2018

ED Medication Room:

28 - B Braun Introcan Safety 14 g (gauge) needles expired 7/2017

An interview was conducted on 3/21/18 at 3:48 PM with EI # 3, RN / ED Nurse Manager, who confirmed the above findings.

Based on review of facility policy and procedures, article in the Association of Peri-Operative Registered Nurse (AORN), Association for the Advancement of Medical Instrumentation (AAMI), observations, and interviews with the staff it was determined the facility failed to ensure the staff:

a) followed the facility policy and procedure for proper hand washing and glove changes.

b) followed the facility policy and procedure for standard precautions and disinfection of medical equipment used during patient care.

c) followed the facility's policy for storing rarely used instruments in surgical services.

Findings include:

Policy: Hand Hygiene
Revised date: 12/14

Policy/ Objective" ... Hand Hygiene

Hand Hygiene measures are the ingle most important prevention strategy for avoiding health care- associated infections (HAI). The hands of personnel serve as a critical reservoir of infection agents.

Procedures:

A. Hand Hygiene Indications
1. Hand hygiene with either waterless hand sanitizer or soap and water is required:

Upon entering and leaving the patient's room

Before donning and after removing gloves.

****

February 19, 2016
Proper packaging ensures integrity of sterilization
By: OR (Operating Room) Manager

Sterilization packaging is considered a medical device and thus it must undergo validation testing before being used in healthcare facilities. To ensure proper packaging that will maintain the integrity of sterilization, consult the packaging manufacturer's instructions for use (IFU) and follow the sterilization standards and guidelines from the Association for the Advancement of Medical Instrumentation (AAMI) and AORN.

Sterilization dating
Contamination of sterile packaging is considered an "event" that can result from a tear, dropped package, wet package, storing the package in a contaminated area, or discovering that a package is already open. Sterile storage is an important factor in event-related dating, which is why the temperature, humidity, and airflow of a storage area must be monitored and documented.

Sterile storage areas must be clean. The labeling of sterilization packaging may include sterility maintenance testing required by the FDA. This means the packaging manufacturer must perform testing that demonstrates the package can sit in a healthcare-simulated environment for a specific amount of time.

Healthcare facilities should follow AAMI and AORN best practices, both of which recommend event-related sterilization dating. Factors that affect the sterility of a package are packaging quality, handling, transport, and storage. A healthcare facility should have written policies and procedures that indicate how shelf life is determined and how it is identified on the package. Stock rotation should be defined by "first in, first out."

According to American National Standards Institute (ANSI)/AAMI ST 79, Comprehensive Guide to Steam Sterilization and Sterility Assurance in Healthcare Facilities, the criteria for a proper environment are:

a) the room must be clean and made of solid materials that can withstand routine cleaning

b) the ventilation should be under positive pressure with a minimum of 4 air exchanges per hour

c) temperature should not be above 75°F, and humidity should not exceed 70%.

The 2015 AORN Guideline for Use of Packaging Systems for Sterilization states, "The shelf life of a packaged sterile item should be considered event-related. The sterility of an item does not change with the passage of time, but may be affected by particular events, example (e.g.) ( amount of handling) or environmental conditions (e.g. humidity)."

Wrapping it up
Sterilization packaging is an important part of the sterilization process. During the packaging selection step, the user should consult the packaging manufacturer ' s IFU to ensure compatibility with the sterilization method.

Maintaining the integrity of the sterile package requires following best practices as described in the ANSI/AAMI ST 79 and AORN guidelines listed in the references below.

References
AORN. Guidelines for perioperative practice, guideline for selection and use of packaging systems for sterilization. Denver, CO: AORN, 2015.

Association for the Advancement of Medical Instrumentation. Comprehensive guide to steam sterilization and sterility assurance in health care facilities. ANSI/AAMI ST 79: 2010 & A1: 2010 & A2: 2011 & A3: 2012 & A4: 2013. www.aami.org.


1. An observation of care was conducted on 3/21/18 at 1:30 PM with Employee Indentifier (EI) # 23, Registered Nurse (RN) who was in a patient room trying to start a Heparin lock (Heplock) on the back of the right hand without success. EI # 21 left the patient's room with both gloves on and holding the used needle and alcohol then proceeded to the nursing station where the used gloves, used needle and alcohol swab were discarded.

2. An observation of care was conducted on 3/21/18 at 2:00 PM with EI # 8, Respiratory Therapist to obtain blood specimen for ABG (arterial blood gas). EI # 8 donned on gloves after performing hand hygiene and proceeded to stick the patient on the right radial area which was unsuccessful. EI # 8 then palpated the artery on the right forearm without changing gloves or performing hand hygiene, stuck the patient with the same needle and syringe and was able to obtain specimen.

EI # 8 and the surveyor left the patient's room with EI # 8 still wearing the same used gloves. EI # 8 removed the right hand glove in the hallway and tried to disinfect right hand by rubbing fingers together (of same hand), then proceeded to disinfect the left hand (with gloves on) wrist area.

EI # 8 and surveyor got on the elevator with EI # 8 holding the test tube full of arterial blood on her gloved left hand while holding the other pair of gloves.

An interview was conducted on 3/22/18 at 3: 15 PM with EI # 18, Nurse Manager who confirmed the above mentioned findings

3. During the tour of the Central Sterile area conducted on 3/2018 at 10:00 AM with EI # 1, OR (Operating Room) Nurse Manager, the following items were found multiple orthopedic instruments, wrapped in blue sterilization wrap located on a 3 tier metal rack underneath 2 markedly stained ceiling tiles

The following orthopedic instruments found:
1. Shoulder Repair Kit x 1 pack
2. Meniscus instruments x 2 packs
3. Triangles X 1
4. Osteotomies x 2 packs
5. Curette x 2 packs
6. Hall Drill x 2 packs
7. Extra Large Drill x 1 pack
8. Large Bone Forceps x 2 packs
9. Reciprocating Saw x 1 pack
10. Oscillating Saw x 1 pack
11. Large to Small Bone Forceps x 2 packs
12. ACL (Anterior Cruciate Ligament Repair x 2 packs
13. Large Drill x 1 pack
14. Small Drill x 1 pack
15. Auto Cuff x 1 pack

These findings were confirmed by the EI # 2 on 3/20/ 18 at 11:15 AM who was with the surveyor during the tour of the Central Sterile Department.




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4. An observation of care on the MICU (Medical Intensive Care Unit) area was conducted on 3/20/18 at 11:09 AM with EI # 24, Registered Nurse to obtain blood glucose test result.

EI # 24 donnedgloves after performing hand hygiene. EI # 24 cleaned the patient's left hand middle finger with an alcohol prep pad and scanned the patient's arm band. EI # 24 removed his/her gloves and donned clean gloves without performing hand hygiene. EI # 24 failed to perform hand hygiene after glove removal per facility policy.

EI # 24 obtained the blood glucose results and removed gloves. EI # 24 proceeded to the nurse's station and donned gloves without performing hand hygiene to clean the the glucometer machine. EI # 24 failed to perform hand hygiene after glove removal per facility policy.

An interview was conducted on 3/20/18 at 11:23 AM with EI # 1, Chief Nursing Officer, who confirmed the above findings.


5. An observation of medication administration on the MICU was conducted on 3/21/18 at 7:57 AM with EI # 25, Registered Nurse.

EI # 25 entered an unsampled patient's room and performed hand hygiene. EI # 25 donned clean gloves and then raised the lid on a red garbage can with his/her gloved hands to throw away trash.

EI # 25 proceeded to open the patient's medication (Enoxaparin Sodium 80 mg [Milligram]) and administered it Subcutaneously with the same gloves used to raise the lid on the red garbage can. EI # 25 failed to remove gloves and perform hand hygiene between touching the garbage can and the administration of the patient's medication.

An interview was conducted on 3/22/18 at 1:06 PM with EI # 5, Director of Professional Standards, who confirmed the above findings.

Based on review on medical records (MR), policy and procedures and interview, it was determined the facility failed to ensure staff provided accurate discharge medication lists. This affected MR# 32, 1of 3 inpatient records reviewed and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Discharge Summary and Instructions
Nursing Discharge Summary and Instructions
Revised date: 8-12

Discharge planning is a dynamic, interdisciplinary process coordinated among patient/ family, Physican, nursing and social services, which prepares the patient for the next phase of care, whether is self-care by family members or care by a provider.

Completion of Nursing Discharge Summary Sheet and Instructions

Ensure that all required elements are addressed both verbally and in writing.
Patients should have any discharge instructions, restrictions, etc, explained carefully.
Instructions are to be written in terms that th patient can understand, to in medical terminology.

Discharge Checklist
The nurse is responsible for ensuring all discharge components are completed and initialed, or has a non-applicable (NA) indicated prior to the patient leaving the hospital.

Home Medication Sheet Completed.

Indicate if prescriptions are attached to the Home Medication Sheet or if the medications are called to a pharmacy.



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1. MR # 32 was admitted to the facility with diagnoses including Acute Abdominal Pain, Hypertension, and Diabetes Mellitus.

Review of the 3/21/18 Discharge Orders Inpatient at 9:10 AM revealed no documentation of when to follow up with the physician, activity level, home medications, and special instructions.

The surveyor requested a copy of all of the discharge instructions provided to the patient including home medications to continue, new medications, and changes made by the physician.

Review of the Home Medication Profile revealed the following duplicated medications and no documentation for the patient to continue, discontinue or hold.

Insulin Lispro Humalog 20 units subcutaneous (SQ) twice a day (BID)
Insulin NPH Humulin N 20 units SQ BID

Prilosec 40 milligram (mg) by mouth (PO) daily
Protonix 40 mg PO daily

Zofran 8 mg PO every 6 hours (hr) as needed (PRN)
Zofran 4 mg PO PRN (no time for how often to take medication)

Oxycontin 40 mg PO BID
Oxycontin 40 mg PO every 12 hours
Oxycontin 10 mg PO every 12 hours

Ambien 10 mg PO PRN (no time)

The surveyor asked Employee Identifier (EI) # 11, (Registered Nurse) which of the above medications did the physician intend for the patient to take at home, were new presciptions written, and what education was provided on new medications. EI # 11 responded "The physician gave the verbal order and wrote new prescriptions. I forgot to make copies of the prescriptions."

In an interview conducted on 3/21/18 at 8:38 AM with EI # 18, RN Supervisor, confirmed the physician and staff failed to provide complete discharge instructions to the patient on discharge.

Based on review of medical records (MR), policy and procedure, Patient Choice Form, and interview, it was determined that 1 of 1 close record reviewed discharge with home health services was referred to a home health agency. The facility failed to give the patient a choice of providers. This affected MR # 40 and had the potential to negatively affect all patients served by this facility.

Findings include:

Policy Title:

Social Services / Discharge Planning - Home Health Referral
Revised Date: 5/2012

Purpose:

When home health services are indicated and physician's order is obtained, home health care arrangements will be made.

Policy:

Per requirement of the 1997 Balanced Budget Act, hospitals as part of their discharge planning process, must provide a list of all home health providers and skilled nursing facilities that serve the area in which the patient resides and who request to be listed by the hospital as available.

Procedure:

When a referral is made for home health services, the Social Services / Discharge Planner / Case Manager must provide the patient and/or significant other with a list of home health providers..."

******

"Patient Choice Form

... Your physician recommended home health care after you leave the hospital. You have the right to select any home care agency to provide the home health care ordered by your physician... A list of home care providers who furnish home care services in the area that you live is attached for your review... Home Health Provider List... Nursing Home Provider List..."

******

1. MR # 40 was admitted to the facility with diagnoses including Unexplained Syncope with Right Knee Injury.

Review of the 2/21/18 Discharge Orders Inpatient at 10:53 AM revealed no documentation of the staff provided the patient and/or significant other with a list of home health providers per facility policy.

An interview was conducted on 3/21/18 at 1:30 PM with Employee Identifier # 22, RN / Case Manager, who confirmed the discharge planner did not document that he/she supplied the patient with a list of home health providers.

Based on review of medical records (MR), facility policies and procedures, Authorization For Transfer Form, and interview with the staff it was determined the facility failed to ensure the staff followed the facility policy and procedure for obtaining patients' / family members' consent for patient transfer to another healthcare facility.

This affected MR # 21, # 12, # 22, and # 20, 4 of 6 patients transferred from the facility and had the potential to negatively affect all patients served by this facility.

Findings Include:

Policy and Procedure: Emergency Department
Revised Date: 8/2016

"Cobra Regulations

Any patient presenting to the Emergency Department with a medical emergency or in labor, has the right to receive, within the capabilities of this hospital's staff and facilities, the following:

... Patient consent should be obtained from patient or family member and reason for transport documented in appropriate area..."

******

Administrative Policies and Procedures: Patient Rights and Responsibilities
Policy Number: 31.24
Revised Date: 12/2002

"A. Patient Rights:

Patients of the Tombigbee Healthcare Authority have the following rights:

... 2. The patient has the right to obtain from his/her physician complete, current information concerning his/her diagnosis, treatment, prognosis, and unanticipated outcomes in terms the patient can reasonably expected to understand...

3. The patient has the right to receive from his/her physician information necessary to give informed consent prior to the start of any procedure and/or treatment. Except in emergencies, such information for informed consent should include but not necessarily be limited to, the specific procedure and/or treatment, the medically significant alternatives for care or treatment exist, or when the patient requests information concerning medical alternatives, the patient has the right to such information...

7. ...When medically permissible a patient may be transferred to another facility only after he/she has received complete information and explanation concerning the needs for and alternatives to such a transfer..."

******

Policy and Procedure: Patient Care Services
Revised Date: 4/2009

"Patient Transfer To Another Facility

... If a valid medical condition exists, the patient shall be treated and retained in the hospital in accordance with medical judgement, or transferred after stabilization, to another facility... If the hospital lacks the ability to treat or stabilize the patient, then transfer must be provided in consideration of the patients request and/or signed certification by the qualified physician...

It is the policy of BWWMH (Bryan W. Whitfield Memorial Hospital), in accordance with federal mandate requirements (COBRA 9121) that all physicians transferring patients shall sign a Transfer Certification form which will be attached to the patients medical records.

When the attending physician transfers a patient to another facility, the following procedure is to be implemented:

... explain the transfer to the patient and the patient's family...

The charge nurse is responsible to assure the following elements are completed and accompanies the patient to the receiving facility:

COBRA form..
Complete Transfer Checklist form..."

******

1. MR # 21 was admitted to the ED on 1/6/18 at 11:54 PM with diagnoses including 7 Months Obstetrics with Seizure.

Review of the Emergency Room Discharge Summary note dated 1/7/18 at 12:21 AM revealed the following documentation: "Valuables given to: Family."

Further review of patient's MR revealed an Authorization For Transfer form dated 1/7/18. The physician's documentation revealed: "The patient has been stabilized such that, within reasonable medical probability, no material deterioration of the patient's condition is likely to result during transfer..." The Authorization For Transfer form was incomplete. The spaces for patient signature and signature and relationship of legally responsible person acting on patient's behalf was left blank. There was no documentation why the staff failed to obtain the patient's and/or authorized person signature per facility policy and procedure.

An interview was conducted on 3/22/18 at 12:31 PM with EI # 3, who confirmed the above findings.

2. MR # 12 was admitted to the Emergency Department (ED) on 1/14/18 at 9:50 AM with diagnoses including Unresponsive.

Review of the Emergency Physician Record note dated 1/14/18 revealed the following documentation: "Baseline: Alert, oriented X (times) 4."

Further review of patient's MR revealed an Authorization For Transfer form dated 1/14/18. The physician's documentation revealed: "The patient has been stabilized such that, within reasonable medical probability, no material deterioration of the patient's condition is likely to result during transfer..." The Authorization For Transfer form was incomplete. The spaces for patient signature and signature and relationship of legally responsible person acting on patient's behalf was left blank. There was no documentation why the staff failed to obtain the patient's and/or authorized person signature per facility policy and procedure.

An interview was conducted on 3/22/18 at 12:31 PM with Employee Identifier (EI) # 3, RN / ED Nurse Manager, who confirmed the above findings.

3. MR # 22 was admitted to the ED on 1/16/18 at 11:59 AM with diagnoses including Chest Pain.

Review of patient's MR revealed an Authorization For Transfer form dated 1/16/18. The physician's documentation revealed: "The patient has been stabilized such that, within reasonable medical probability, no material deterioration of the patient's condition is likely to result during transfer..." The Authorization For Transfer form was incomplete. The spaces for patient signature and signature and relationship of legally responsible person acting on patient's behalf was left blank. There was no documentation why the staff failed to obtain the patient's and/or authorized person signature per facility policy and procedure.

An interview was conducted on 3/22/18 at 12:31 PM with EI # 3, who confirmed the above findings

4. MR # 20 was admitted to the ED on 2/20/18 at 10:55 AM with diagnoses including Water Broke / Obstetrics Patient.

Review of the Emergency Room Discharge Summary note dated 2/20/18 at 10:53 AM revealed the following documentation: "Patient accompanied by: Family."

Further review of patient's MR revealed an Authorization For Transfer form dated 2/20/18. The physician's documentation revealed: "Patient is in active labor..." The Authorization For Transfer form was incomplete. The spaces for patient signature and signature and relationship of legally responsible person acting on patient's behalf was left blank. There was no documentation why the staff failed to obtain the patient's and/or authorized person signature per facility policy and procedure.

An interview was conducted on 3/22/18 at 12:31 PM with EI # 3, who confirmed the above findings.

Based on review of medical record (MR), Clinical Protocol for Wound Management and Wound Management Standards, policy and procedure, and interview, it was determined the facility failed to ensure the Physical Therapy Department:

a) had the ability to identify patient's admission/ discharge date to Outpatient Rehab Services and document toward goals identified to the current plan of care.

b) followed the physician's order for wound care in 1 of 2 closed records

c) Obtained physician orders for wound care

d) Obtained physician orders for the frequency PT visits.

e) Provided discharge planning instructions for wound care.

f) Failed to identify the type of wound and obtain complete past medical history.

g) Had policy and procedures that identified

1.) How wounds should be identified, or measured, how often the Wound Care/ Integumentary Management contained measurements of wounds.
2.) How often the paraffin bath would be cleaned and documented.

This affected MR # 31 and had the potential to affect all patients served by this facility with wounds.

Findings include:

Clinical Protocol for Wound Management and Wound Management Standards
June 2013

"Rationale
The aim of this document is to provide the appropriate manage strategy for optimum wound healing, ...in line with best practice/ evidence.

All wounds must be assessed and re-assessed by a competent, registered health care professional who will undertake a comprehensive assessment of the wound (site, size, surface, grade, and appearance, exudate type and volume, state of surrounding skin and level of wound pain)...

Trust Wound Care Standards...

Reassessment of the wound should be undertaken at every dressing change, and documented... at a minimum of weekly or more frequently depending on wound presentation...

Initial and on going wound assessment...
Necrotic tissue:
Wound containing dead tissue may appear hard, dry and black; Eschar with time may soften by autolysis...
Necrotic tissue in Ischemic leg ulcers should be left dry- moist wound healing is not promoted.

Slough:
Slough is formed by an accumulation of dead cells in the wound exudate. It is light yellow in color and must not be confused with infected tissue or pus...

Wound measurement is vital to monitor the healing process of a wound..."

****

Wound Care/ Integumentary Management
Facility Policy
Date: 1/11/16

"This policy will provide guidelines for the management of patients who present with partial or full thickness wounds and would benefit from physical therapy intervention...

This policy will focus on the following types...
-Pressure Ulcers
-Venous Stasis Ulcers
-Arterial Insufficiency
-Surgical Wounds and grafts
-Burns

It is important to note that some guidelines may be different wound surgeon /physician given his or her preferred practice. Therefore it is necessary to refer to the physician's order for appropriate patient management...

For in-patient population, wound care will be turned over to nursing when it is no longer indicated for skilled PT (Physical Therapy) services. Recommendations will be made to nursing prior to discharge.
If a referral for wound care is made and PT determines no skilled PT is indicated, recommendations will be made to nursing and patient discharged."


1. A tour of the Outpatient Rehab Services was conducted on 3/20/18 at 3:00 PM the surveyor requested a list of patients seen by the Outpatient Therapy with admission date for the past 60 days.

Review of the list of patients 1/18/18 to 3/19/18 provided to the surveyor same patient names with different numbers and different admission dates.

The surveyor asked Employee Identifier (EI) # 20, Director of Rehab Services, "Do you have a system in place that allows the Outpatient Rehab department to print a list of patients currently receiving therapy and that tracks patients from admission to discharge, including current physician orders?" The response was "No"

In an interview conducted 3/20/18 at 4:00 PM with Employee Identifier (EI) # 10, Director of Health Information Management, confirmed each visit is treated as a new admission date (visit date).

2. MR # 35 was admitted to the Outpatient Services for Cellulitis, Wound Right Lower Extremity.

Review of the Physician's Order dated 1/11/18 revealed wound care to be provided daily with the duration of 1 week.

Review of the 1/12/18 PT Evaluation note revealed the wound measurements of 15 centimeter (cm) Length (L) by (X) Diameter 4 cm X 1.5 cm Depth (D). 100 % yellow eschar, minimal drainage. There was no documentation of the color of the drainage of the wound, or the width (W) of the wound on admission.

Further review of the 1/12/18 PT evaluation note revealed "treatment provided selective debridement of necrotic tissue with tweezers and scissors, cleansed with wound cleanser and packed with 1 inch packing, covered with dry 4 X 4 gauze, kling and secured with tape. Patient was educated on keeping tissue dry. Patient to be seen tomorrow..."

Review of 1/15/18 PT Progress Note revealed documentation the wound was debrided, redressed with Silvasorb packing, 4 X 4 gauze, kerlix and tape. There was no documentation of the wound bed, or drainage and no documentation the patient was educated on this wound care.

Review of the 1/16/18 PT Progress Note revealed documentation the patient complained of itching at periwound site. The wound was debrided less than 20 cm and irrigated thoroughly with wound cleanser, scrubbed with dry 4 X 4, repacked wound with damp to dry 4 X 4, covered with dry dressing. Periwound approximately 1 inch appear angry.

There was no documentation of the therapist reported to the physician the itching, or periwound, description of the wound bed or drainage. There was no documentation the patient was educated on the wound care provided.

Review of the 1/18/18 PT Progress Note revealed no documentation of description of drainage.

Review of the 1/19/18 PT Progress Note revealed documentation of dark edges noted at periwound, purplish in color approximately 1 inch with continued itching. There was no documentation the physician was notified of the wound changes.

Review of the 1/19/18 PT Progress Note /Physician Orders revealed the documentation of: The patient received 7 treatments.

Treatment received: "Debridement of non-viable, tissue from wound edges, and wound beds, application of appropriate dressings, teaching patient home care of wound.

Assessment: Wound bed demonstrates 80% yellow eschar with only 20% beefy red granulation tissue, erythema noted at periwound at 1 inch... Also reports itching at periwound.

Recommendations:
Patient needs continued skilled PT to allow full healing.

There was no physician orders to continue PT Services with frequency and duration and no date the physician signed the form.

The surveyor asked Employee Identifier (EI) # 20, Director of Rehab Services, if the patient received 7 treatments or 5. The response was 5 and stated "we are only open Monday - Friday".

Review of PT Progress Notes dated for 1/22/18, 1/24/18, 1/26/18, 1/30/18, 2/1/18, 2/6/18, 2/9/18, 2/13/18, and 2/16/18 revealed documentation the Outpatient Therapy Department provided care without physician orders.

In an interview conducted on 3/21/18 at 1:30 PM with Employee Identifier (EI) # 20, Director of Rehab Services, confirmed the above findings.

2. MR # 34 was admitted to the facility on 3/15/18 with diagnoses including Cellulitis Right Lower Extremity, Diabetes, Diastolic Heart Dysfunction, Chronic Renal Failure and High Blood Pressure.

Review of the Physician's Verbal order on 3/15/18 at 4:56 PM revealed "clean wound to right lower extremities with Karaklenz. Cover with Xeroform gauze and cover with 4 X 4 and abdominal (ABD) pad and wrap with kling."

Review 3/16/18 PT Evaluation Note revealed documentation including
"Wounds: patient has an open decubitus non-healing stage 3 to right lower leg, 8 cm high X 5 cm wide X 0.5 cm deep with a mild amount of serosanguineous drainage.

Assessment: Evaluation and wound care for right lower leg and education for nursing care for follow up.

Goals: Nursing staff will educated on wound dressing and care for right lower leg wound.
Today's Treatment: Cleansed with Microklenz ,followed by Xeroform gauze applied, covered with sterile 4 X 4, ABD pad and wrapped with Kerlex and secured with paper tape..."

The surveyor requested from EI # 20, documentation of the education the PT provided to the nursing staff for the non-healing stage 3, decubitus and who was educated. There was no documentation the PT educated the nursing staff on wound care.

In an interview conducted on 3/22/18 at 12:40 PM with EI # 20 confirmed the above findings.

Based on facility policy and procedure, medical record review and interview with staff it was determined the facility failed to demonstrate evidence of an ongoing activities program with scheduled activities to promote quality of life for patient's admitted to the swing-bed program.

This affected 1 of 3 records reviewed including Patient Identifier (PI) # 3 and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Swing Bed/ Patient Care Services (Medical Records)
Revised: 12-03

Purpose

To provide a guidelines for the maintenance of swing bed medical records.

Procedure

All information relating to the health plan of the patient shall become part of the medical record. The medical record shall include.

***
Policy: Swing Bed Policy
Updated: 3/20/18

Purpose
To provide activities for wing Bed patients. Bryan W. Whitfield Memorial Hospital has patients who routinely are admitted for a short stay for swing Bed services which may be inappropriate to some activities, as well as their medical condition may be prohibitive. Each patient is assessed and a plan developed for their specific needs as related to activities.

Policy

2. The activities director or designee under th direction of the activities director, will prepare a plan of care to include specific patient goals.


1. Medical Record (MR) # 3 was admitted to Swing Bed on 3/2/18 for rehabilitation and strengthening.

The surveyor visited the patient's room on 3/20/18 at 2:20 PM. Patient stated she not doing well, has oxygen on but still short of breath. When the survyor asked if she has calendar of activities, she said " I don't know what your are talking about". The surveyor noted there was no calendar of activities posted in the patient's room.

Review of the medical records on 3/20/18 at 2:30 PM revealed an Activity Approval Sheet that had the patient's Recreational Preference which had a check mark under movie, woodworking and others, Long Term Goals, " return to previous activities" was written, Short Term Goals had "increase physical stamina and tolerance" was checked. Plan and Goal was left unmarked.

The surveyor interviewed the Activity Program Director, Employee Identifier (EI) # 22, Registered Nurse (RN) on 3/20/18 at 3:15 PM who stated he/ she visits the swing bed patients and gives them items they might like to do in their hospital rooms such as cross word puzzles, word search, etcetera (etc).
EI # 22 further stated she/ he does not have a patient calendar of activities developed or posted for the department staff to follow.