HospitalInspections.org

Based on review of medical records (MR), interview with the administrative staff, it was determined the facility failed to ensure Consent for Treatment (CFT) and Conditions of Admissions (COA) were signed prior to the delivery of care for 11 of 30 Emergency Room (ER) records and for 1 of 19 MR records reviewed.

This affected ER # 1, ER # 8, ER # 9, ER # 13, ER # 14, ER # 15, ER # 20, ER # 21, ER # 22, ER # 23, ER # 30 and MR # 5 and had the potential to negatively affect all patients served by the facility.

Finding include:

1. ER # 1 was seen in Atmore Community Hospital (ACH) ER Department (ED) on 10/11/14 with the diagnoses including Soft Tissue Injury to Left Shoulder and Seizures.

Review of patient's ED record revealed the CFT and COA were not signed by the patient and/or family member prior to triage and assessment.

An interview with Employee Identifier (EI) # 1, Quality Improvement (QI) Coordinator was conducted on 1/29/15 at 11:00 AM who confirmed the above mentioned findings.

2. ER # 8 was seen in ACH ED on 10/13/14 with diagnoses including Stroke and Chest pains.

Review of patient's ED record revealed the CFT and COA were not signed by the patient and/or family member prior to triage and assessment.

An interview with EI # 1 was conducted on 1/29/15 at 11:05 AM, who confirmed the above mentioned findings.

3. ER # 9 was seen in ACH ED on 10/2/14 with the diagnosis including Assault and Inflammation Involving Groin.

Review of the ED record revealed the CFT and COA were not signed by the patient and/or family member prior to triage or treatment.

An interview with EI # 1 was conducted on 1/29/15 at 11:10 AM, who confirmed the above mentioned findings.


4. ER # 13 was seen in ACH ED on 10/16/14 with the diagnosis of Seizure Disorder.

Review of the ED record revealed the CFT and COA were not signed by the patient and/or family member prior to triage or treatment.

An interview with EI # 1 was conducted on 1/29/15 at 11:30 AM, who confirmed the above mentioned findings.

5. ER # 14 was seen in ACH ED on 10/7/14 with the diagnosis of Suicidal Thoughts.

Review of the ED record revealed the CFT and COA were not signed by the patient and/or family member prior to triage or treatment.

An interview with EI # 1 was conducted on 1/29/15 at 11:35 AM, who confirmed the above mentioned findings

6. ER # 15 was seen in ACH ED on 10/8/14 with the diagnosis of Active Labor.

Review of the ED record revealed the CFT and COA were not signed by the patient and/or family member prior to treatment.

An interview with EI # 1 was conducted on 1/29/15 at 11:40 AM, who confirmed the above mentioned findings.

7. ER # 20 was seen in ACH ED on 11/7/14 with the diagnosis of Suicidal Thoughts.

Review of the patient's ED record revealed the consent treatment form was not signed by the patient and/or family prior to treatment.

An interview was conducted on 1/29/15 at 11: 45 AM with EI # 1 who confirmed the above mentioned findings.

8. ER # 21 was seen in ACH ED on 11/9/14 with the diagnosis of Motor Vehicle Accident with Injury to the Posterior Neck/ Cervical Spine and Lower Portion of the Face.

Review of the patient's ED record revealed the consent treatment form was not signed by the patient and/or family member prior to triage and assessment.

An interview was conducted on 1/29/15 at 11: 50 AM with EI # 1, who confirmed the above mentioned findings.

9. ER # 22 was seen in ACH ED on 12/8/14 with diagnoses including Anxiety, Chest pains and Hallucination.

Review of the patient's ED record revealed the consent treatment form was not signed by the patient and/or family member prior to triage and assessment.

An interview was conducted on 1/29/15 at 11: 55 AM with EI # 1, who confirmed the above mentioned findings.

10. ER # 23 was seen in ACH ED on 1/5/15 with diagnosis of Feeling Sick.

Review of the patient's ED record revealed the consent treatment form was not signed by the patient and/or family member prior to triage and assessment.

An interview was conducted on 1/29/15 at 12:10 PM with EI # 1 who confirmed the above mentioned findings.

11. ER # 30 was seen in ACH ED on 10/18/14 with the diagnosis of Back Pain.

Review of the patient's ED record revealed the consent treatment form was not signed by the patient and/or family member prior to triage and assessment.

An interview was conducted on 1/29/15 at 12: 20 PM with EI # 1, who confirmed the above mentioned findings.

12. MR # 5 was admitted 1/12/15 with the diagnosis of Infected Decubitus.

Review of the admission record on 1/12/15 revealed there was no documentation the consent for treatment was obtained.

An interview was conducted on 1/29/15 at 12:30 PM with EI # 1, who confirmed the above mentioned findings.

Based on the review of Medical records (MR), facility policy and procedures, observation and interview the facility staff failed to:

1. Document wound measurements

2. Document specific wound care provided

3. Have orders for wound care provided

4. Follow the policy for isolation and teach the patient and family regarding isolation to protect family and the public.

This affected MR # 5 and MR # 6, 2 of 2 wound care records reviewed and had the potential to affect all patients and the public served by this facility.


Findings Include:


Policy and Procedure:

Document No: 3101-370
Date Effective: 7/2014
Title: Wound Assessment Packet
Policy:

" 3. A wound information form will be completed on patients identified with skin breakdown on admission and patients who develop skin breakdown during hospitalization. ...

4. All wounds will be photographed and a photo will be placed in the medical record. ...

6. A photograph of existing skin breakdown will be taken on admission and PRN (as needed) thereafter. ...

8. The effectiveness of treatment will be evaluated and documented. ..."


Document No: 3101-372
Date effective: 7/2014
Title: Wound Care

Purpose:
" To provide optimum nursing care to minimally active patients by stimulating circulation and preventing or relieving pressure. ...

Stage III and IV

1. Follow protocol for stage II but provide wound care as prescribed per M.D. (Medical Doctor).

2. Obtain M.D. order for nutritional consult.

3. Obtain M.D. order for physical therapy."


Policy No. 5602.-220
Date Effective: 2/2007
Revised: 2/2008
Title: Isolation Precautions

" Key Function
Infection Control Prevention

Hand Washing and Gloving

Handwashing frequently is called the single most important measure to reduce the risk of transmitting microorganisms from one person to another, or from one site to another on the same patient. ...

II. Standard Precautions

Use Standard Precautions, or the equivalent, for all the care of all patients.

A. Hand Hygiene...B. Gloves...C. Mask, Eye Protection, Face Shield...
D. Gown...

V. Contact Precautions

In addition to Standard Precautions, use Contact Precautions, or the equivalent,for specified patients known or expected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the patient (hand or skin-to-skin contact that occurs when performing patient-care activities that require touching the patient's dry skin) or indirect contact (touching) with environmental surfaces or patient-care items in the patient's environment.
...
B. Gloves and Hand Washing

In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, non-sterile gloves are adequate) when entering the room. During the course of providing care for a patient change gloves after having contact with infective material that may contain high concentration of microorganisms (fecal material and wound drainage). ..."


1. MR # 6 was admitted to the facility on 12/27/14 and discharged on 1/4/15 with a diagnosis of Draining Wounds.

Review of the initial nursing assessment dated 12/27/14 at 5:01 PM revealed documentation of 6 wounds identified as follows:

A. Right shoulder (burn), 6 cm (centimeters) L (length) X (by) 4 cm W (wide), no depth documented, dressing type = 4 X 4 gauze.

B. Right thigh (burn), 1 cm L X 1 cm W x 0.5 cm D (deep), dressing type = 4 X 4 gauze.

C. Right hip (burn), "100" cm L X 2 cm W X 0.5 cm D, dressing type = ABD ( abdominal pad)/telfa.

D. Left back (epidermal tear/shear), 1 cm L X 1 cm W no depth documented, dressing type = open to air .

E. Left shoulder (burn), 4 cm L X 6 cm X 0.5 cm D, dressing type = ABD/ telfa.

F. Right leg (laceration), no measurements documented, dressing type = telfa.

Review of the physician's orders dated 12/27/14 revealed wound care orders as follows: Dress wounds with Gentamycin BID (2 times a day).
There was no documentation of the route or dose of the Gentamycin.

Review of the skilled nurse (SN) notes from 12/27/14 to 1/4/15 failed to include documentation of wound care provided.

The physician's order was incomplete and did not include a method of cleaning the wound or the type of dressing to apply to each wound.

There was no documentation the physician was contacted to clarify the wound care orders.

An interview conducted on 1/29/15 at 10:30 AM with Employee Identifier (EI) # 1, Quality Assurance (QA) Manager, verified there was no clarification of the incomplete order or wound care documentation in the MR.

2. MR # 5 was admitted to the facility 1/2/15 with a diagnosis of Infected Decubitus and discharged on 1/20/15.

Review of the Wound Care Report dated 1/2/15 at 3:30 PM through 1/20/15 at 7:30 AM failed to include wound measurements and stage of the wound identified as a "pressure ulcer" (pu).

Review of the physician's order dated 1/3/15 at 10:00 PM revealed an order as follows: "1/2 strength Dakins wet to dry to wound on coccyx".
The order did not include a solution for cleansing the wound, a dressing to be used to cover the wound, what to secure the dressing with or how often the wound care was to be performed.

Review of the medical record from 1/2/15 to 1/20/15 failed to include any documentation the physician was contacted to clarify orders for wound care to the pu on the patient's coccyx.

Review of the Wound Care Report revealed wound care as follows:

" 1/3/15 at 4:07 PM Dressing Status = dry and intack, Dressing Type = 4 X 4's, ABD...

1/4/15 at 3:08 AM Dressing Status = changed, Dressing Type = 4 X 4's, ABD, Wound (WD) Treatment = cleaned with saline moist, wet to dry dressing placed with Dakins...

1/5/15 at 6:07 AM Dressing Status = saturated/mod (moderate) drng (drainage) 25-50%, WD Treatment = Changed, cleansed with Dakins solution and wet to dry dressing applied with an ABD pad...

1/5/15 at 7:40 Dressing Status = mod drng 25-50%,
WD Treatment = 4 x 4's/ABD, cleaned with Dakins solution wet to dry... "

Review of the SN documentation on the Wound Care Reports dated 1/6/15 through 1/10/15 was the same as above.

Review of the Wound Care Report dated 1/11/15 revealed Xeroform gauze was added to the wound care. There was no physicians order for Xeroform or Vaseline gauze.

Review of the Wound Care Reports dated 1/11/15 through 1/20/15 revealed the same wound care as documented above. There was no orders for the above documented wound care.The Xeroform and Vaseline gauze was documented interchangeably.

An interview conducted on 1/29/15 at 10:30 A M with EI # 1,who verified there was no documentation to reveal contact was made to the physician for clarification of wound care orders. There was no order provided to perform wound care as documented.



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Observation of EI # 4, Licensed Practical Nurse (LPN), was conducted on 1/27/15 at 1:05 PM.

While providing a medication pass, EI # 4 was called to assess MR # 5 which was on Contact Isolation precautions.

Upon entering MR # 5's room, EI # 4 failed to perform hand hygiene before donning gloves and gown. MR # 5 had a paid caregiver wiping blood from MR # 5's nose with a tissue and was not wearing gloves.There was no education given to the caregiver regarding wearing gloves.

EI # 4 assessed the patient's vital signs including blood pressure, temperature, and oxygen saturations.

EI # 4 retrieved an ink pen from his/her shirt pocket to write down vital sign readings.

EI # 4 did not remove contaminated gloves or perform hand hygiene before reaching under isolation gown to obtain ink pen.

After writing down the findings, EI # 4, replaced the ink pen into his/her pocket without removing gloves or performing hand hygiene.

EI # 4, placed his/her soiled gloves and gown in a container with a black trash can liner in the trash can, not a red biohazard bag.

After providing care to MR # 5, EI # 4 and EI # 1 left the room, the door to the room was left open. There was no instructions given to the caregiver regarding the need to keep the door closed.

The surveyor also observed the following opened containers in MR # 5's room with no date of when they were opened:
2- Normal Saline (NS) 1000 milliliter (ml)
1- Sterile Water 1,000 ml

EI # 1, QA Manager identified the NS and Sterile Water were used for MR # 5"s wound care.

The hospital failed to follow acceptable practice for Contact Isolation and Standard Precautions and protect the patient's paid caregivers, staff and patients from potential infection.

In an interview conducted on 1/27/15 at 2:00 PM with EI # 1, the aforementioned findings were confirmed.

Based on review of the Dietary Policy and Procedure Manual, and interviews with staff, the facility failed to ensure the Dietary policy and procedure manual was reviewed and approved by the medical staff. This had the potential to negatively affect all patients served by this facility.

Findings include:

During a tour of the Dietary Department conducted on 1/28/15 at 7:00 AM with Employee Identifiers (EI) # 7, Dietary Manager and EI # 6, Registered Dietitian, it was determined there was no documentation the medical staff had approved the Dietary Policy and Procedures since 2004.

An interview was conducted on 1/28/15 at 3:00 PM with EI # 6 and EI # 7 the aforementioned findings were confirmed.

Based on interview and review of the current diet manual, the facility failed to have a current diet manual which was approved by the dietitian and medical staff.

Findings include:

The online diet manual provided by the Employee Identifier (EI) # 6, Registered Dietian (RD) and the dietary staff revealed no documentation the online diet manual had been approved by the dietitian or the medical staff.

In an interview conducted on 1/28/15 at 7:30 AM with the EI # 6 the aforementioned findings were confirmed.

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.

Findings include:

Refer to Life Safety Code violations.

Based on observations and interviews with facility staff it was determined the facility failed to ensure all medical supplies available for patient use in the Outpatient Department were stored properly and not expired.

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

Findings include:

A tour of the Outpatient Department was conducted on 1/28/15 at 2:30 PM with Employee Identifier (EI) # 5, Director of Outpatient Therapy.

During the tour of the Outpatient Department, the surveyor observed the following:
1) 2 pair used scissors,
2) a blue towel containing 2 pair of scissors,
3) 2 pair of tweezers
4) 2 pair of hemostats.
EI # 5 was unsure of how long these instruments had been in or around the sink.

The following biological's and supplies were expired:
1) 4 Bactroban 0.5 milliliter (ml) ointment packages expired 10/14,
2) 8 Megasorb Calcium Alginate wound dressings expired 5/14,
3) 2 Culturette Swabs expired 3/14.
4) a 30 ml (milliliter) bottle of Dexamethasone almost empty with no date the bottle was opened,
5) an unsterile single use 5 cc (cubic centimeter) syringe. EI # 5 stated the syringe was used repeatedly to access the bottle and apply medication to dressing before applying to multiple patients.
4) a 3 cc bottle of Lidocaine 5 % /Dexamethasone cream. This was not labeled with a patient's name.
5) a 500 ml container of Sterile Water which was half empty and had no date it was opened.
6) 5 plastic clear cups with blue lids that were labeled with 5 different patient names.

The surveyor questioned the contents of the 5 cups and asked if these patients were current. EI # 5 looked in computer to see if the patients were currently receiving care and verified only 1 was a current patient.

An interview was conducted on 1/29/15 at 10:30 AM and the aforementioned findings were confirmed.

Based on review of the medical record and interview it was determined that physical therapy outpatient services did not notify the Physician of a frequency change from the original therapy plan of care.

This affected 1 of 2 physical therapy outpatient records reviewed, Medical Record (MR) # 16 and had the potential to negatively affect all patients being served by this facility.

Findings include:

The facility had no current policy regarding physician notification of changes in the plan of care.

1.MR # 16 was admitted for physical therapy outpatient services on 11/12/14 with a diagnosis of Spine Post-laminectomy syndrome, lumbar region. The physician's ordered frequency was for 3 times a week for 4 weeks.
The week of 11/12/14 the patient only received therapy 2 times.
The week of 11/23/14 the patient only received therapy one time.
The patient was re-evaluated on 12/5/14 and was ordered to continue Plan of Care at 3 times a week for 4 weeks.
The week of 12/14/14 the patient only received therapy 2 times.
The week of 12/21/14 the patient only received therapy 2 times.
The patient was re-evaluated on 12/30/14 and was ordered to continue Plan of Care at 3 times a week for 4 weeks. The patient received therapy only 2 times for that week.
The week of 1/11/15 the patient only received therapy 2 times.

An interview was conducted on 1/29/15 9:00 AM with Employee Identifier (EI) # 5, Director of Rehabilitation Services and the above findings were verified.