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Based on record review, interview, and policy review, the facility failed to complete monthly monitoring to ensure that emergency supplies (used when a patient's health deteriorates to near death) were adequate and maintained according to the facility's policy. This had the potential to affect all patients in the facility. The facility census was 12.

Findings included:

1. Record review of the facility's policy titled "Universal Crash Cart Management" revised on 02/11, showed that equipment and adequate supplies were maintained on crash carts through monthly and daily checks.

2. Record review on 08/02/11 at 9:50 AM showed that the form titled, "Universal Crash Cart Supplies" showed monthly checks of the crash cart were not completed in the Intensive Care Unit (ICU) for February 2011 and June 2011.

3. Record review of the form titled, "Universal Crash Cart Supplies" showed monthly checks of the crash cart were not completed on the Medical/Surgical (M/S) floor for February 2011 and May 2011.

4. Record review of the form titled, "Universal Crash Cart Supplies" showed monthly checks of the crash cart were not completed in the Operating Room (OR) for February 2011 and April 2011.

During an interview on 08/02/11 at 1:55 PM, Staff N, Manager of the ICU and M/S stated that crash carts should be checked monthly.

Based on observations, interviews, and policy review, the facility failed to follow policy and standard of practice CDC (Centers for Disease Control and Prevention) guidelines for infection control in hand washing and glove use for three patients (#3, #5, and #18) of three patients during four observations. The facility census was 12.

Findings included:

1. Record review of the facility's policy titled, "HAND-HYGIENE" dated 05/08/06, showed direction for facility's staff to perform the following hand hygiene procedures:
-Before and after patient contact;
-Between patient contact;
-Before and after gloving;
-After contact with unclean surfaces.

2. Record review of facility's policy titled, "Transmission Based Precautions" dated 05/27/03, showed the following direction to facility staff:
-Precautions referred to a "Standard Precautions" are designed to reduce the risk of contact exposure to bloodborne and other infections/communicable diseases. HMC [Hedrick Medical Center] recognizes Standard Precautions as an integral part of the care of all patients (inpatient and outpatient). For some patients additional precautions are necessary due to the mode of transmission (airborne, droplet, or contact) for their suspected or confirmed infections/communicable diseases. These precautions are called Transmission Based Precautions. Some limitations of movement and social contact may be necessary in Transmission Based Precaution situations.
-Standard Precautions - All HCW should routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure when contact with blood, body fluids, secretions, excretions or contaminated items of any patient is anticipated.
-Handwashing - Wash hands after touching blood, body fluids, secretions, excretions and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, between patient contacts and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. It may be necessary to wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites.
-Gloves - Wear gloves (clean, nonsterile gloves are adequate) when touching blood, body fluids, secretions, excretions and contaminated items. Put on clean gloves just before touching mucous membranes and nonintact skin. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environments.

3. The facilities policy titled, "HAND-HYGIENE" dated 05/08/06, referenced CDC Guideline for Hand-Hygiene in Health-Care Settings, MMWR October 25, 2002/51(RR16): 1-44 that states the following:
- Indications for hand hygiene
· Contact with a patient's intact skin (e.g., taking a pulse or blood pressure, performing physical examinations, lifting the
patient in bed)
· Contact with environmental surfaces in the immediate vicinity of patients
· After glove removal.

4. Observation on 08/02/11 at 8:45 AM showed Patient #3 with an intravenous line (IV) (a thin plastic tube inserted into a vein [usually in the patient's forearm] through which a volume of fluid is injected into the bloodstream). Staff E, RN (Registered Nurse) donned gloves to administer the patient's medication. Staff E continued to wear the same gloves to type data into the computer, check the IV line, handle the patient's gown and remove the patient's IV. Staff E donned new gloves without performing hand hygiene. Staff E inserted a new IV line into the patient's vein, causing small amounts of blood to surface on the outside of the patient's arm. Staff E removed the IV insertion and while still wearing the same gloves began touching the patient all over looking for another IV insertion site. Staff E then removed one glove on the left hand, picked up contaminated supplies on the patient's bed and threw then in the trash container. Staff E picked up the unused supplies off the patient's bed with the same hand and put them back into the clean IV supplies caddy to be used for another patient(s). Staff E removed the glove from the right hand and used hand hygiene gel rather than washing with soap and water.

Staff C, RN, Quality Manager stated the nurse should not have removed only one glove and should have performed hand hygiene with soap and water after glove removal.

During an interview on 08/03/11 at 1:30 PM, Staff Q, Infection Control RN, stated that when gloves come in contact with a patient or their environment, the gloves should be removed and hand hygiene should be performed between glove changes.

5. Record review showed Patient #5 had been admitted with severe diarrhea awaiting results of a test for c-diff (Clostridium difficile: a type of spore bacterium [an extremely small organism] that can cause serious illness and that is very difficult to treat, highly infectious, and difficult to prevent from spreading to others).

Observation on 08/02/11 at 1:45 PM showed Staff H, PCA (Patient Care Assistant) removed soiled gloves and without performing hand hygiene touched the items on the bedside table before performing hand hygiene.

6. Observation on 08/03/11 at 2:15 PM showed Staff S, RN, wore gloves to remove Patient #5's peripherally inserted central catheter (PICC) (a long, slender, small, flexible tube that is inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart to obtain direct intravenous access). Staff S proceeded to slowly remove the PICC line from the vein that was covered with the patient's blood. After Staff S removed the PICC line, he/she held pressure on the vein opening with the right hand and removed her left glove and had another nurse put on a clean glove without performing hand hygiene. Staff S, without changing his/her right glove, used both hands to place a new bandage on Patient #5's PICC line.

Staff C, RN, Quality Manager, stated he/she didn't understand why the nurse only removed one glove and didn't perform hand hygiene.



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7. Observation on 08/02/11 at 9:35 AM showed Staff L, RN, contaminated the end of Patient #18's intravenous (IV) tubing when he/she touched the connecting port of the tubing with his/her non-sterile, gloved hand. Staff L then connected the port to to Patient #18's main IV tubing to infuse antibiotics.

During an interview on 08/03/11 at 1:30 PM, Staff Q stated that anytime IV tubing becomes contaminated, it should not be used, and should be discarded.

Based on observation, interview, record review, and policy review, the facility failed to continuously monitor a patient on telemetry (monitors a patient's heart rate and rhythm, blood pressure, breathing, and oxygen levels) for one (#18) of one patient observed on telemetry. This had the potential to allow deterioration (worsening of condition) of the patient and could affect any patient on telemetry monitoring. The facility census was 12.

Findings included:

1. Record review of the facility's policy titled "Electrode Placement and Application of Hardwire Monitoring or Telemetry Monitored Patients," revised on 07/11/08, showed that monitoring of the telemetry will be completed accurately with close observation to detect changes in the cardiac rhythm for early diagnosis and intervention.

2. Record review of Patient #18's current medical record showed the physician wrote an order for telemetry on 08/01/11 at 3:42 PM.

Observation on 08/02/11 at 9:07 AM, showed Patient #18 on telemetry in the ICU without a nurse present, indicating the patient was not being monitored. At 9:10 AM, Staff L, RN (Registered Nurse), exit a bathroom and enter the nurses' station where the telemetry monitor was located.

During an interview on 08/02/10 at 9:10 AM, Staff L stated the telemetry monitor had alarms that sound if there was a change in the patient's status and he/she could hear the alarms while in the bathroom.

Observation on 08/02/11 at 9:15 AM of the telemetry monitor showed an alarm sound due to Patient #18 experiencing an irregular heart rhythm. Further review of the telemetry monitor showed that the patient had the following telemetry alarms occur:
-Irregular heart rate at 8:33 AM;
-High respiratory rate of 42 (normal is 12 - 20) at 8:53 AM;
-Irregular heart rate at 8:57 AM.

During an interview on 08/02/11 at 9:20 AM, Staff L stated the House Nursing Supervisor relieved staff for breaks and during meal times, but he/she was not contacted to monitor the patient while Staff L was in the bathroom.

Based on interview, record review and policy review, the facility failed to ensure the physicians' verbal/telephone orders were signed, timed and dated within 48 hours for four(Patients #1, #3, #5, and #8) of nine current medical records reviewed and for four (Patients #11, #12, #13 and #15) of 11 discharged medical records reviewed. The facility census was 12.

Findings Included:

1. Record review of the facility's Medical Staff Bylaws and Rules and Regulations, #9, amended and revised on 10/22/09 showed the following:
-Orders dictated over the telephone shall be documented by the person taking the order with the name of the practitioner, per his or her own name.
-All verbal orders must be authenticated (signed, dated, and timed) within 48 hours.

2. Record review of the facility's policy #NR/G-1, entitled "Medication Delivery Process," dated 03/03/10 stated the following:
-Orders should be designated as verbal order (V/O) if received face-to-face or telephone order (T/O) if received via telephone or if written orders are received. The responsible practitioner should co-sign, date and time the order within 48 hours.

3. Record review of the facility's policy titled, "Physician orders - Verbal, Telephone and Copied" revised on 02/05/07, showed that a licensed practitioner's written order should include the date and time that the order was issued, and that verbal or telephone orders should be co-signed by the responsible practitioner, dated, and timed.

4. Record review of Patient #1's current medical record on 08/02/11 showed the facility failed to have the following verbal and/or telephone orders timed, dated and signed within 48 hours of the order:
-T/O dated 07/30/11 at 6:00 AM for Lortab 5/325 one tablet every 4 hours and prn (as needed).
-A read back verbal order (RBVO) dated 07/30/11 at 6:20 AM to obtain a complete blood count (CBC) (a broad screening test used to check for certain medical disorders) and a basic metabolic panel (BMP) (eight lab tests used as screening tool) on 07/30/11 at 7:00 AM.

5. Record review of Patient #5's current medical record on 08/02/11 showed the facility failed to have a read back verbal order (RBVO) dated 07/29/11 at 8:40 AM for Occupational Therapy (OT) to evaluate and treat signed within 48 hours of the order:

During an interview on 08/02/11 at 2:35 PM, Staff P, Director of Health Information Management stated that he/she recognized the facility's physicians had a problem in timing, dating and sign V/O and T/O orders, but felt the problem continued to improve. He/she stated his/her staff prepare daily delinquent reports and communicate with the physicians on a daily basis to improve the delinquent status and he/she monitored the delinquent records and reported monthly in the hospital's Performance Improvement Committee meetings.



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6. Record review of Patient #8's current medical record showed a physician's order for Percocet (pain medication) was dated and signed on 08/01/11, but was not timed.

7. Record review of Patient #11's closed medical record showed a physician's order for Tylenol and Motrin (pain medications) was dated and signed on 08/01/11, but was not timed.

8. Record review of Patient #12's closed medical record showed a physician's order for Decadron (reduces inflammation), Diptheria and Tetanus (immunization), and Benadryl (used to decrease or prevent allergic reactions) was dated and signed on 08/01/11, but was not timed.

9. Record review of Patient #13's closed medical record showed a physician's order for Flagyl and Cipro (both antibiotics) was dated and signed on 06/19/11, but was not timed.

10. Record review of Patient #15's closed medical record showed a physician's order for Protonix (decreases gastric acids), Reglan (decreases nausea), Potassium (used to replace a low potassium in the blood), and Morphine (pain medication) was dated and signed 05/27/11, but was not timed.

During an interview on 08/01/11 at 3:55 PM, Staff J, Emergency Department (ED) Manager stated all entries in the medical record should include a date and time along with the physician's signature.


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11. Record review of Patient #3's current medical record showed the following T/O's were missing one or a combination of either a signature, date or time:
- 07/27/11 at 4:28 PM for Sodium Chloride (also known as salt, common salt, table salt or halite, is an ionic compound used in the treatment of dehydration) intravenously (within the vein);
-On 07/27/11 at 3:55 PM for Normal saline (a sterile solution for fluid and electrolyte replenishment) intravenously; Accucheck (a method of blood sugar testing) daily; EKG (electrocardiogram is a simple, painless test that records the heart's electrical activity); Oncology consult for lung mass; and a regular diet;
-On 07/27/11 at 5:15 PM for a Dietary consult and house supplements BID (twice per day;
-On 07/28/11 at 8:00 AM for telemetry monitoring (a way to provide constant monitoring of your heart); Cardiology (heart specialist) consult for abnormal EKG and PT (Physical Therapy) evaluation;
-On 07/28/11 at 10:20 AM to decrease normal saline to 75 mL/hr (milliliters per hour);
-On 07/29/11 at 8:15 AM to change IV fluids to 50 cc/hr (cubic centimeter per hour); Megace (indicated for the treatment of appetite loss, severe malnutrition, or unexplained, significant weight loss ) 400 milligram by mouth daily;
-On 07/31/11 at 2:10 PM to maintain saline lock (IV access) with routine flushes.

Based on interview, record review and policy review, the facility failed to ensure the physicians signed, dated and timed entries for two (Patients #1, and #5) of nine current medical records reviewed and one (Patient #26) of 11 discharged medical records reviewed. The facility census was 12.

Findings Included:

1. Record review of the facility's Medical Staff Bylaws and Rules and Regulations, #9, amended and revised on 10/22/09 showed the following:
-Orders dictated over the telephone shall be documented by the person taking the order with the name of the practitioner, per his or her own name.
-All verbal orders must be authenticated (signed, dated, and timed) within 48 hours.

2. Record review of the facility's Health Information policy entitled "Authentication of Medical Record Entries," dated 01/01/06 showed the following:
-All entries in medical records are signed, dated, and timed and its author identified.
-To verify physician's signatures, you may refer to the Medical Staff Application form.
-Authentication may be written signature or initials, or electronic signatures.

3. Record review of facility's policy #NR/G-1, entitled "Medication Delivery Process," dated 03/03/10 stated the following:
Each medication order should include:
-Date and time that the order was issued.
-Orders should be designated as verbal order (v/o) if received face-to-face or telephone order (t/o) if received via telephone or if written orders are received. The responsible practitioner should co-sign, date and time the order within 48 hours.

4. Record review of Patient #1's current medical record on 08/02/11 showed the facility failed to ensure the physician timed the following:
-An order dated on 07/30/11 for Protonix 40 mg (milligrams) IVPB (Intravenous Piggy Back) q (every) day.
-All dictation notes dated between 07/28/11 through 08/01/11
-A Progress note dated 07/30/11 stating the following: Afib (a common heart rhythm disorder), pulse 84, respiration 20, B/P (Blood Pressure) 146/61 and Sats (saturation level) 94%.

5. Record review of Patient #5's current medical record on 08/02/11 showed the facility failed to ensure the physician timed an order dated 07/24/11 for Torodol (pain medication) 30 mg (milligrams) IV (Intravenous); PICC Line consult and placement; Librium (anxiety medication) 50 mg po (by mouth) qid (four times daily); Metopradol (blood pressure medication) 25 mg po and complet blood count, complete metabolic panel, Lipase and Amalase lab tests in the AM.

The Physician's progress notes dated 07/24/11 to 07/29/11 were not timed.

6. Record review of Patient #26's current medical record showed the physician dated the " Emergency Physician Record on 02/11/11, but did not include the time.

During an interview on 08/02/11 at 2:35 PM, Staff P, Director of Health Information Management, stated that he/she recognized the facility's physicians had a problem in timing, dating, and authenticating orders and entries in the records, but felt the problem continued to improve. He/she stated his/her staff prepare daily delinquent reports and communicate with the physicians on a daily basis to improve the delinquent status and he/she monitored the delinquent records and reported monthly in the hospital's Performance Improvement Committee meetings.

Based on observation, staff interview, the facility staff failed to have sufficient safeguards to ensure the access to all information regarding patients was limited to those individuals designated by law, regulation and policy caring for the patients. The facility census was 12.

Findings Included:

During review on 08/02/11 at 2:30 PM of the Health Information Management (HIM) Department, Staff P, Director of HIM stated the hours of operation for the department were from 8:00 AM to at least 5:00 PM daily, Monday through Fridays.

During interview on 08/02/11 at 2:30 PM, Staff P stated Staff T, Engineering Director, had keys to access the HIM department and two clinical records storage areas. Staff P stated Staff T needed access to the clinical records storage rooms and department in the event the facility had a fire or water damage.

Observation on 08/03/11 at 3:45 PM of the two clinical records storage areas in which Engineering staff had access to showed the rooms contained shelves and boxes of patients' complete clinical records. The desk and countertop had complete patients' clinical records stacked on top of them.

Based on interview, the facility failed to ensure that patients placed in physical restraints were monitored for appropriate use and safety of the restraint by failing to do quality monitoring of restraint use. This had the potential to affect any patient placed in physical restraints. The facility census was 12.

Findings included:

1. During an interview on 08/02/11 at 10:30 AM, Staff C, Quality Director, stated the facility did not maintain a log of patients who were placed in restraints, could provide only one record from the previous year of patients who had been placed in restraints, and that the facility did not do quality monitoring for safety of patients placed in restraints.

During an interview on 08/02/11 at 2:15 PM, Staff O, Registered Nurse (RN), stated the facility did use restraints on patients.

Based on observation, interview, record review, and policy review, the facility failed to have a qualified Social Services Director/Manager over the Social Services Department on a part time or consultant basis. This had the potential of affecting all patients in the facility. The facility census was 12.

Findings included:

1. Record review of the facility's position description titled, "Manager, Utilization Review and Case Management," revised 07/23/10, showed the following requirements for the position:
-The position required responsibility for leadership of the Multidisciplinary Case management at Hedrick Medical Center inclusive of utilization management, social service, Swing Bed placement and oversight of the Multidisciplinary discharge Team. The manager would function as both employee and manager, providing professional social work services to all Hedrick Medical Center customers and required the ability to collaborate with various disciplines and facilities within and outside the Hospital System, including managed care organizations, extended care providers and regulatory agencies.
-Education Required for Position: Bachelor's Degree - Required, Master's Degree - Preferred;
-Certification/Registration/Licensure/Other;
-Nursing or Social Work licensure;
-Management Level - Manager;
-Experience (years) 2-5 years.

2. During an interview on 08/01/11 at 3:45 PM, Staff D, Utilization Review and Social Services Manager, stated he/she has an Associate's Degree in Nursing. Staff D stated there were two people in the department; Staff D is mainly responsible for Utilization Review and Staff U, Social Services Designee and Case Management Assistant had the responsibilities of patient discharge assessments, planning, community resources and patient placement if required.

3. Record review of the facility's personnel file for the current Manager of Social Services, Staff D, showed the following:
- Licensed since 06/1997 as a Registered Nurse and worked as a charge nurse in a medical facility performing direct patient care;
- Previous job titles: Utilization Management Analyst and RN (Registered Nurse) Charge Nurse.
Staff D's previous job history did not show 2-5 years experience as a departmental manager as required per the job description.

4. Record review showed Patient #1 had been admitted on Friday, 07/29/11. An interview with Patient #1 on 08/01/11 at 2:35 PM and record review revealed no social services assessment or discharge planning had been completed.

During an interview on 08/01/11 at 3:45 PM, Staff U, Social Services Designee and Case Management Assistant, stated Patient #1 had been admitted on Friday and he/she still had not been able to assess the patient or help with discharge planning. Staff U stated they have their discharge planning meetings on Tuesdays and Thursdays and no one is available on the weekends to assist/interview/assess patients with discharge planning. Staff U stated he/she has been trained as a Social Service Designee and if "we get into trouble we call a Social Worker from Home Health/Hospice", but that the Home Health/Hospice employee was not an employee of the hospital or consultant by agreement with the facility.

5. During an interview on 08/03/11 at 3:15 PM, Staff D, Utilization Review and Social Services Manager, stated that Staff U sees all the patients and does the Case Management and Discharge Planning but he/she will assist him if they have too many patients. Staff D stated that he/she contacted a Social Worker from their sister facility if he/she needed direction but that there was no formal agreement with that person and they were not an employee of the facility. Staff D stated that during any sort of leave or time off from the facility that Staff U is the only one at the facility to meet the discharge planning and social service needs of the patients.

6. During an interview on 08/04/11 at 8:50 AM, Staff C, RN (Registered Nurse), Quality Manager, stated that Staff D had been hired by the former Chief Nursing Office and that administration were aware that his/her qualifications did not meet the facility's job description.