HospitalInspections.org

Based on review of departmental policy, observation, review of medical records and procedure manuals and interviews with staff, the facility failed to:

1. Review the policy and procedure departmental manuals annually.

2. Follow the policy for checking the crash cart daily in the emergency department and nursing services.

3. Follow the policy for certification and re-certification of Swing Bed patient stays. This affect Medical Record (MR) # 3 and # 4 current swing bed patients. This had the potential to affect all patients admitted to the Swing Bed program.

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


Findings include:

Policy & Procedure: Crash Cart Checks

Purpose: To ensure that all of the crash cart equipment, drugs and supplies are functional, stocked appropriately and in date.

Policy: The charge nurse in each area of nursing service will be resposible for doing crash cart checks daily, monthly and after each use.

Procedure:

" 1. Check that all equipment on the formulary is present and functioning properly at the beginning of each shift...
5. After performing the required checks, in the appropriate place, it is the responsibility of the nurse to sign the date, time, nurses name/initials and shift that each crash cart was checked..."


Policy & Procedure: Certification/ Re-certification of Swing Bed stay.

Purpose: To comply with Medicare/Medicaid guidelines.

Policy: It is the policy of Jackson Medical Center that any patient admitted to the Swing Bed Program will have their stay re-certified appropriately by their attending physician in compliance with Medicare/ Medicaid guidelines.

Procedure: " Upon admission to the Jackson Medical Center Swing Bed Program, the Swing Bed Screening Criteria form will be completed by the Swing Bed Coordinator or other designee as appropriate... When completed, this form should be given to the patient's attending physician for review and approval. The attending physician will then be asked to sign the screening criteria form indicating initial certification of the patient's stay in the swing bed program.

Prior to the 14 th day of swing bed stay, a re-certification form, including adequate documentation of continued need for swing bed care, an estimated period of time the patient will need continued care, and a plan for discharge care. This will constitute the first re-certification and will be completed prior to the 30 th day of stay thereafter..."

***

During a tour of the emergency department 4/22/14 at 9:55 AM, the policy and procedure book for the emergency department was reviewed. The surveyor noted the last review and revision date in the front of the book was 2/2013.

Employee Identifier (EI) # 1 the Chief Administrative Officer provided the policy and procedure books from the different departments 4/22/14 at 3:00 PM.

A review of the books included the following information:

Nursing Service Policy and Procedure book reviewed and revised 01/2011.

Swing Beds Policy and Procedure book reviewed and revised 09/2013, signed only by the Swing Bed Coordinator, the Administrator did not sign the form.

There was no documentation of an annual review of the policies and procedures and no, "updated review" sheet was available for review when requested by surveyor.

An interview conducted on 4/22/14 at 11:57 AM with EI # 3, Director of Nursing, confirmed annual updates to Nursing Service policy and procedures had not been performed.

In an interview 4/23/14 at 10:30 AM EI # 1 confirmed the annual review of the policy and procedure books was an ongoing process and some of them were behind.

***

On 4/22/14 at 9:45 AM the surveyor toured the emergency department.

During the tour the surveyor reviewed the Nursing Service Crash Cart checklist for Pediatrics February 2014 with the following dates not initialed as having been completed:

2/2/14, 2/3/14, 2/17/14, 2/18/14, 2/19/14, 2/21/14, 2/22/14, 2/26/14, 2/27/14 and 2/28/14.

During the tour the surveyor reviewed the Nursing Service Crash Cart checklist for Pediatrics March 2014 with the following dates not initialed as having been completed:

3/5/14, 3/6/14, 3/22/14, 3/23/14, 3/25/14, 3/26/14, 3/28/14, 3/29/14 and 3/30/14.

During the tour the surveyor reviewed the Nursing Service Crash Cart checklist for Pediatrics April 2014 with the following dates not initialed as having been completed:

4/2/14, 4/4/14, 4/5/14, 4/16/14, 4/17/14 and 4/24/14.

During the tour the surveyor reviewed the Nursing Service Crash Cart checklist for Adult April 2014 with the following dates not initialed as having been completed:

4/2/14, 4/5/14, 4/17/14 and 4/21/14. The nurse present stated that she had worked the 21st and knew she checked the cart and signed the form in the surveyor's presence.

In an interview 4/23/14 at 10:30 AM EI # 4, Emergency Room Nurse confirmed the above information regarding the Crash Cart checks not being completed daily.

During the 4/22/14 12:00 PM tour of the nursing unit, the surveyor observed the Nursing Service Crash Cart checklist for April 8, 2014 was not initialed as having been monitored daily as per policy.

An interview conducted on 4/22/14 12:02 PM with EI # 3 confirmed staff failed to perform 4/8/14 documentation for monitoring of the nursing service crash cart.

***

1. MR # 3 was admitted to the Swing Bed services on 4/18/14 with a diagnosis of Osetomyelitis of the Left Great Toe.

The surveyor reviewed the medical record 4/23/14 and the record failed to contain a signed certification for the Swing Bed or a current history and physical.

In an interview with EI # 5, the Nurse Manager, 4/23/14 at 2:30 PM was asked about the signed certification. EI # 5 did not provide any additional information about the certification form.

In an interview 4/24/14 at 9:00 AM with EI # 1, the Chief Administrative Officer, she produced a signed certification dated 4/23/14 and confirmed no history and physical was present in the record and the physician signed the form after it was brought to EI # 5's attention.

2. MR # 4 was admitted to the Swing Bed services on 4/8/14 status Open Reduction and Internal Fixation with hardware removal of the Left Hip.

A review of the medical record by the surveyor 4/23/14 failed to have documentation of the 14 day re-certification which was due 4/22/14.

In an interview 4/24/14 at 9:00 AM with EI # 1, the above information was confirmed.

Based on review of medical records, policy and procedures, observation and interview it was determined the facility failed to inform each patient and/or representative, both inpatient and outpatient of the patient's rights. As part of its notification of patient rights, the hospital must provide the patient or the patient's representative a phone number and address for lodging a grievance with the State agency.

This affect 42 of 42 records reviewed. This had the potential to affect all patients served by this facility for both inpatient and outpatient care.

Findings include:

Policy & Procedure
Subject: Patient Rights & Responsibilities

Jackson Medical Center wants to provide the best possible care for the patients as prescribed by the physician. In providing this care, we want the patient to be fully aware of their rights as a patient, as well as, any obligations the patient have to themselves, the physician and the hospital.

The review of medical records failed to reveal any documentation the patient or representative had been provided information regarding patient rights.

Observation of the lobby of the hospital and the emergency department entrance on 4/22/14 at 9:45 AM failed to have patient rights posted and failed to include the State toll-free phone number for lodging a complaint or grievance.

In an interview 4/22/14 at 2:25 PM with Employee Identifier # 2, the CEO (Chief Executive Officer) regarding patient rights she provided a brochure to the surveyor titled," Jackson Medical Center...Patient Rights and Responsibilities." When asked if the brochure was provided to all patients, EI # 2 stated that it was posted on the wall in registration and provided to the patient if they requested a copy.

EI # 2 confirmed they were not providing all patients with a copy of the patient rights.

Based on observations and an interview with administrative staff, it was determined the hospital failed to post instructions informing patients of their right to file a grievance with the State agency. This had the potential to affect all patients receiving services from the hospital.

Findings include:

During a tour of the emergency department 4/22/14 at 9:55 AM it was observed the hospital did not have the toll free State Hot Line number posted for patients in the front hospital lobby and emergency entrance waiting area to voice grievances.

In an interview with Employee Identifier #1, the Chief Administrative Officer 4/22/14 at 2:00 PM confirmed the above.

Based on review of medical records, review of policy and procedures and interview it was determined the facility staff failed to:

1. Measure wounds weekly.

2. Obtain physician orders for wound care prior to providing wound care.

3. Follow up on Nutritional Assessments on patients at risk.

4. Follow insulin orders as written.

This had the potential to affect all patients served by this facility and did affect 4 of 12 records reviewed. This affected Medical Record (MR) # 2, # 3, # 4 and # 12.

Findings include:

Policy and Procedure: Nutritional Assessments

Policy: It is the policy of this facility that a nutritional assessment be completed for any patient identified as having a nutritional risk.

Purpose: To identify patients who may benefit from nutritional intervention to maintain or improve their nutrition status.

Procedure:
"1. The Case Manager or her designee will gather screening data on all patients, within 24 hours of admission...

2. Adults will be identified at potential nutritional risk if any of the following are noted:
a. Presence of a Stage 3 or 4 decubitus;
b. Significant unplanned weight loss of 10 pounds of more in the past month;
c. Patients whose diagnosis or presenting signs/symptoms indicates a compromised nutritional status (...electrolyte imbalances, Malabsorption...);
e. Patients whose medical condition can be adversely affected by their nutritional intake (diabetes, congestive heart failure, patients taking certain medications...).

3. The Case Manager/designee will notify the Dietary Manager of patients identified as having Nutritional risk factors.

4. Once a patient is identified at potential risk, Dietary Manager will complete an assessment within 24 hours of notification.

5. Dietary Manager will notify physician of dietary recommendations and consult with physician as needed.

6. Follow up assessments will be conducted as needed."


Policy and Procedure: Wound Assessment

Purpose: To provide guidelines for the documentation of assessment and measurement of wounds.

Procedure:
" 1. Wounds should be assessed by the wound care nurse weekly during admission.

2. Nursing Care Staff (RN [Registered Nurse]/ LPN [Licensed Practical Nurse]) will assess wounds with their daily assessments unless ordered differently. If dressing must stay in place longer than 24 hours ( per physician's orders) then appearance of the dressing and surrounding skin will be assessed every shift...

5. Measure and document the wound in centimeters.

a. Length measurement
i. Consider wound as a face of a clock. 12:00 points to the patient's head, 6:00 points to the patient's feet. Length equals 12:00- 6:00; width equals 3:00 - 9:00 side to side...

b. Depth measurement is distance from visible surface to the deepest area...

c. Tunneling/Undermining measurement
i. Measure and document depth and direction...

6. Documentation should include and assessment of the wound bed...

8. Describe the condition of the skin surrounding the wound.

9. Conclude with documentation of care of the wound to include wound cleanser and type of dressing applied."

Medical Record findings:

1. MR # 3 was admitted to the Swing Bed service 4/18/14 with diagnoses of Left Great Toe Osetomyelitis and Insulin Dependent Diabetes Mellitus.

The physician orders dated 4/18/14 included orders for, " Wound care: Clean wound with NS (normal saline), add silver alginate and cover daily... BS (blood sugar) 7, 11, 4 and 9 with MDSS (Medical Doctor Sliding Scale)... weight today and every Friday, nutritional assessment..."

The Wound Assessment form documented no measurement 4/19/14, 4/20/14 and 4/21/14. There was nothing documented on the Wound Assessment form for 4/18/14 date of admission to the Swing Bed and 4/22/14.

The nurse measured the wound 4/23/14 after the surveyor observed wound care. The wound measurement was documented as length: 5 cm (centimeter), width: 4 cm and no depth was documented. The nurse documented the appearance of the wound bed to be slough/ drainage small amount of tan thick stringy in appearance.

The nurse failed to document a depth to this open wound.

The Nutritional Assessment/ Screening form was completed 4/22/14 documented, " I. Nutrition factors- nothing was marked on the form.
II. Lab values- Nothing was marked on the form- out beside the choices it was written by hand (none at this time).
III. Based on Above Data- Patient's Nutritional Status within normal limits."

The form was signed by the Dietary Manager.

In an interview with Employee Indentifer (EI) # 5, the Nurse Manager, 4/23/14 at 2:30 PM she was asked if anyone reviewed the Nutrition Assessment forms. EI # 5 stated not that she knew of but it was a good idea.

This patient was at nutritional risk due to his insulin dependent diabetes mellitus, open wound, long history of Osetomyelitis with plans to amputate his left great toe and long term use of intravenous antibiotics.

In an interview with EI # 1, the Chief Administrative Officer, 4/24/14 at 9:00 AM, the above information was confirmed.

2. MR # 4 was admitted to the Swing Bed service 4/8/14 with diagnosis of Status Post Open Reduction and Internal Fixation of left hip with hardware removal.

The Nutritional Assessment/ Screening form was completed 4/22/14 and documented, " I. Nutrition factors - 2. BMI (Body Mass Index) 24.
II. Lab values- Nothing was marked on the form.
III. Based on Above Data- Patient's Nutritional Status within normal limits."

The form was signed by the Dietary Manager.

The patient had resided on the Swing Bed unit from 4/8/14 until 4/22/14 before the assessment was completed.

In an interview with EI # 5, the Nurse Manager, 4/23/14 at 2:30 PM she was asked if anyone reviewed the Nutrition Assessment forms. EI # 5 stated not that she knew of but it was a good idea.

In an interview with EI # 1, the Chief Administrative Officer 4/24/14 at 9:00 AM, the above information was confirmed.

3. MR # 12 was admitted to the facility 4/21/14 with diagnoses of Diabetes Mellitus Insulin Dependent, Hypertension and Coronary Artery Disease ( Post Mitral Valve surgery 3 weeks ago).

On 4/21/14 the nurses notes included documentation, " 12:05 PM, Transferred to floor to room...1800 (6:00 PM) has raw areas buttock- cleaned- duoderm applied- also has raw area left.. (unable to read) duoderm applied."

The physician's order sheet dated 4/22/14 included orders written at 7:30 AM, " Change duoderm to sacrum every 72 hours."

The physician's order sheet dated 4/22/14 included orders written at 1:20 PM, " Humulin 75/25- 20 units every AM, fasting and 4 PM blood sugar daily."

The Medication Administration Record (MAR) included the following information:
Duoderm to sacrum change every 72 hours applied 4/22/14 with the dates of 4/22/14 marked out with an X, with the next time to apply duoderm designated on 4/24/14.
Humulin 75/25 insulin 20 units sq (subcutaneous) each AM. Written out beside this in a different handwriting inside parenthesis was (Use Novolog 70/30) this was not dated or signed.

The duoderm was applied 4/21/14 without an order. The MAR transcription of the order was incorrect in it was first applied 4/22/14, however the 72 hour change date was correct for 4/24/14.

The MAR documented 4/22/14 at 1345 (1:45 PM) Humulin 75/25 insulin 20 units sq (subcutaneous) each AM, initialed as administered.

The MAR documented 4/23/14 at 7:30 AM initialed as administered with the same handwriting of the (Use Novolog 70/30).

In an interview with EI # 1, the Chief Administrative Officer 4/24/14 at 9:00 AM, the above information was confirmed. EI # 1 stated that there was a note in the medication room that Novolog and Humulin were the same.



30952

3. MR # 2 was admitted to the facility 7/25/13 with diagnoses of Bilateral Pneumonia, Respiratory Failure and Stage III Pressure Ulcer to the Coccyx.

Review of documentation revealed MR # 2 resided in a nursing facility and received Juven nutritional supplementation twice daily (Juven supports tissue repair).

The Nutritional Assessment/ Screening form was completed and documentation included the following: "...Diet Order: Healthy Heart...Weight 95 (pounds)...II. Lab values- 2.8 Albumin-less than 3.0 (Protein Status)...III. Based on Above Data- Patient may be considered at Nutritional Risk or require nutritional intervention.

The form was signed by the Dietary Manager, but not dated. There was no documentation of the Stage III Pressure ulcer.

Review of the medical record failed to include interventions to manage the nutritional risks identified above.

In an interview with EI # 5 on 4/24/14 at 9:00 AM, it was confirmed there was no follow up by the staff or physician to address MR # 2's nutritional risks.

Based on review of Pharmacy and Therapeutic Committee meetings documentation, policy and interviews, it was determined staff failed to conduct Quarterly Pharmacy and Therapeutics Committee meetings. This had the potential to affect all patient's served.

Findings include:

Facility Procedure
No Date

9.8 Pharmacy and Therapeutics Committee
9.8-2 Duties
The duties of the pharmacy and therapeutics committee shall include:
(a) assisting in the formulation of professional practices...regarding the...use, safety procedures...relating to drugs in the hospital...
(d) developing and reviewing a formulary...
(g) maintain a record of all activities relating to pharmacy and therapeutics functions...

9.8-3 MEETINGS
The committee shall meet as often as necessary...but at least quarterly. It shall maintain a record of its proceedings and shall report...to the medical executive committee."


On 4/23/14 at 1:30 PM, a tour of hospital pharmacy services and interview with Employee Identifier (EI) # 13, Pharmacy Director was performed.

EI # 13 reported to the surveyor the Pharmacy and Therapeutics Committee meets "quarterly". Review of the Pharmacy and Therapeutics Committee meetings documentation revealed meetings were conducted as follows:

Three times in 2012, on 2/21/12, 6/14/12 and 8/14/12.
Two times in 2013, on 4/4/13 and 12/24/13.

Review of the Pharmacy and Therapeutics Committee records failed to include quarterly meeting documentation as per facility policy.

On 4/24/14 at 7:30 AM, a request was made to EI # 13 for additional documentation and none was provided.

During an interview on 4/24/14 at 10:00 AM, EI # 1, Chief Administrative Officer, verified the finding.

Based on observation, policy and procedures and interview with facility staff it was determined the facility failed to ensure all medications and biological's available for patients were not expired. The facility failed to ensure all multi-dose vials were labeled with the date opened. This had the potential to affect all patients served by this facility.

Findings include:

Policy & Procedure: Opening/ Dating Sterile Vials

Policy: As set forth by the Clinical Services Committee, sterile items for parenteral use shall be discarded after a specific length of time after opening as follows:

" Multiple Dose Vials (with preservative): Discard 30 days after opening. ( Must be labeled with date of puncture, date of expiration and initials of person puncturing)...
All expired solutions shall not be dispensed and shall be discarded.
All solutions shall be stored with the earliest expiring items in front.
All open vials found which do not have the date and initials of the person puncturing shall be immediately discarded."


Policy & Procedure: Nursing Service

" Medications/ Intravenous Fluids: Multiple dose vials are to be dated when opened, initials of person puncturing, stored appropriately and disposed of 30 days after opening."


On 4/22/14 at 9:45 AM the surveyor toured the emergency department.

The surveyor observed the following medications and solutions opened and not labeled:
Morphine 20 ml (milliliter) vial had been punctured and not labeled.
Lidocaine 1% 20 ml vial opened and not labeled.
Lidocaine 2% 20 ml vial opened and not labeled.
0.9% NS (normal saline) irrigation solution a 1000 ml bottle opened with approximately 200 ml left in the bottle opened and not dated.
0.9 % NS irrigation solution 500 ml bottle with approximately 300 ml left in the bottle opened and not dated.

In an interview 4/23/14 at 10:30 AM EI # 4, Emergency Room Nurse confirmed the above regarding medications and solutions and disposed of the materials.

On 4/22/14 at 10:15 AM the surveyor toured the nursing unit including the medication room and nourishment refrigerator.

The surveyor observed the following medications, solutions, nourishments opened and not labeled or expired and available for use:

2 Glucerna 1.2 calories 8 ounce cans, expired 3/1/14.

Povidone Iodine solution 8 ounces, 1 bottle, expired 9/2012

Methergine 1 ml (0.2 mg [milligrams]) 2 vials expired 3/2014.
Carafate 1 gram(g)/ml, 14 ounces, 1 bottle opened and not labeled.
Prednisolone Oral solution 240 ml, 1 bottle opened and not labeled.
Lactulose 10 g/15 ml, 16 ounces, 1 bottle opened and not labeled.
Pro-Stat 101, 30 ounces, 1 bottle opened and not labeled.
Robitussin 4 ounces, 1 bottle opened and not labeled.
Children's APAP (acetaminophen) 4 ounces, 1 bottle opened and not labeled.
Hycodan syrup 1.5 mg per 5 ml, 1 bottle opened and not labeled.
Norco 7.5 mg/325 mg per 15 ml, 1 bottle opened and not labeled.
Tylenol with Codeine 120 mg/12 mg per 5 ml, 1 bottle opened and not labeled.
Morphine Sulfate 20 mg/ml, 1 bottle opened and not labeled.

The Hycodan, Norco, Tylenol with Codeine and Morphine Sulfate was prepoured and labeled by the pharmacist. The bottles were opened and there was no date when first used.

The surveyor observed the following supplies that were expired during the tour.

22 red top clot activator 5 ml lab specimen tubes, expired 2/2014.
40 red top clot activator 5 ml lab specimen tubes, expired 9/2013.
The lab tubes were found in the nursing floor stock cabinet available for patient use.

In an interview on 4/22/14 at 10:55 AM, EI # 3 confirmed the findings.


During a 4/22/14 1:40 PM tour of the surgical department, one 8 ounce bottle of Povidone Iodine solution expired 1/2014 was found in the malignant hyperthermia cart. Plastic baggies that contained four red lab specimen tubes, expired 2/14, four purple lab tubes, expired 2/14 and four green lab tubes, expired 1/14 were available for patient use.

An interview on 4/22/14 at 1:45 PM was conducted with EI # 12, Certified Registered Nurse Anesthetist, Surgery Manager, who confirmed the findings and removed the expired supplies.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to affect all patients served.

Findings include:

Refer to Life Safety Code violations.

This condition is not met based on observations, facility policy review and staff interview, it was determined the facility failed to:

1. Follow it's policy on handwashing.

2. Perform cleaning of the equipment according to manufacturer's recommendations and guidelines for equipment disinfection and sterilization.

3. Use disposable equipment for 1 patient only.

4. Wear appropriate PPE (Personal Protective Equipment) during procedures.

5. Properly store Operating Room (OR) equipment.


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

Findings include:

Refer to A 749 and A 951 for additional findings.

Based on The Centers for Disease Control Guidelines for Hand Hygiene in Health-Care Settings, facility policy, manufacturer's recommendations, observations and interviews, it was determined the facility failed to:

1. Follow it's policy on handwashing.

2. Perform cleaning of the equipment according to manufacturer's recommendations and guidelines.

3. Use disposable equipment for 1 patient only.

4. Wear appropriate PPE (Personal Protective Equipment) during procedures.

5. Properly store Operating Room (OR) equipment.


This had the potential to negatively affect all patients and staff in the facility.

Findings include:

www.cdc.gov
Morbidity and Mortality Weekly Report
Recommendations and Reports October 25, 2002 / Vol. 51 / No. RR-16
Centers for Disease Control and Prevention

Guideline for Hand Hygiene in Health-Care Settings
Recommendations for Hand Hygiene

"...C. Decontaminate hands before having direct contact with patients
F. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, lifting a patient)
I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient
J. Decontaminate hands after removing gloves..."

www.cdc.gov
Guidance for the Selection and use of Personal protective Equipment (PPE) in Healthcare Settings

"...Program Goal
Improve personnel safety in the healthcare environment through appropriate use of PPE.
...Definition
"specialized clothing or equipment worn by an employee for protection against infections material" (Occupational Safety Health Agency)
OSHA issues regulations for workplace health and safety...require use of PPE...to protect healthcare personnel from exposure to bloodborne pathogens...
The CDC issues recommendations for when and what PPE should be used...
Types of PPE Used in Healthcare Settings
...Gloves, protect the hands...are the most common type of PPE used in healthcare settings...Gloves protect you against contact with infectious materials..."


Facility Policy Number 3009
Hand Hygiene
No Date

" II. Purpose:
...To reduce to as low as possible, the number of viable microorganisms on the hands in order to prevent transmission of healthcare associated pathogens form one patient to another, and to reduce the incidence of healthcare associated infections.

If hands are not visibly soiled, use an alcohol-based hand rub for decontaminating hands in all other clinical situations. Examples:

Before direct contact with a patient's intact skin...
After skin or mucous membrane contact...
After contact with inanimate objects(including medical equipment) in the immediate vicinity of the patient..."


Manufacturer Use Instructions
Precision Glucose Meter Orientation
"...Cleaning the meter
11. Maintenance...

Cleaning the Exterior Surface
Acceptable cleaning solutions include alcohol and ammonia based cleaners. Recommended solutions are Sani-Cloth? HB, Sani-Cloth? Plus, and Super Sani-Cloth?. Bleach or hydrogen peroxide based cleaners will fade the monitor keypad. Hype-Wipe?, Dispatch? and Virox? 5 wipes are not recommended as they may fade the monitor keypad. Cleaning solutions not listed have not been tested and may damage the monitor...


Facility Policy Number 5034
No Date
"...Patient Care Equipment and Supplies:
All disposable items/supplies are for one patient use only, and are discarded as appropriate..."


Observations were made on 4/22/14 at 12:25 PM with Employee Identifier (EI) # 8, Registered Nurse (RN) during a medication (med) pass.

During the med pass # 1, EI # 8 entered the med room, opened and removed the unsampled patient's Medication Administration Record (MAR). EI # 8 retrieved Nitrobid 2 % and the paper patch. EI # 8 applied Nitrobid to the patch, folded the patch in half and exited the med room. EI # 8 opened the supply door and retrieved a new roll of tape. EI # 8 then entered the patient's room, gathered gloves and verified the patient's armband and MAR dosing. EI # 8 laid the MAR on the patient's hospital bed and donned gloves. EI # 8 removed the previously applied patch and wiped the left chest site with a paper towel. EI # 8 applied the 2 % Nitrobid 1/2 inch patch and secured with tape.

EI # 8 removed gloves, performed hand hygiene and exited the room with the MAR and tape on her clipboard. EI # 8 returned to the med room and replaced the MAR in the holder.

EI # 8 failed to perform hand hygiene prior to the medication preparation and before donning gloves. EI # 8 laid the MAR on the hospital bed, a contaminated site, and returned it to the the medication room which is a clean work area. EI # 8 removed the single use disposable tape from the patient's room and brought the tape to the medication room.

On 4/22/14 at 12:35 PM, EI # 8 entered the med room, obtained the MAR, retrieved an oral narcotic from the locked cabinet and placed the medication in the paper pill cup. EI # 8 did not perform hand hygiene prior to preparation of the patient's medication.


A tour of the OR department was conducted 4/22/14 at 2:20 PM with EI # 12, Certified Nurse Anethestist, Surgery Manager. Outside the 2 OR suites, was a door labeled " Caution Anesthesia". An open box of OR head pillows, carbon dioxide absorbers and anesthesia circuits were observed on the floor.


On 4/23/14 at 10:55 AM, glucometer testing on 2 unsampled patients was observed with EI # 7, the Nursing Assistant. EI # 7 gathered the plastic carrier containing the Precision glucometer and testing supplies, entered the room and performed hand hygiene. EI # 7 cleaned the patient's finger with an alcohol prep pad and performed the capillary blood glucose testing. EI # 7 applied an alcohol prep pad to the patient's finger, held pressure to the site and disposed of the alcohol prep pad. EI # 7 placed the glucometer in the plastic carrier, disposed of the lancet to the sharps container, performed hand hygiene and exited the room.

EI # 8 then repeated this procedure on 4/23/14 at 11:05 AM on the second unsampled patient.

EI # 8 did not wear gloves during the capillary blood glucose testing procedure. EI # 8 failed to disinfect the glucometer between patient use.

An interview on 4/23/14 at 11:10 AM with EI # 8 confirmed the above observations.


During a 4/23/14 2:40 PM med pass observation on the nursing unit, EI # 9, RN entered the med room, opened the MAR holder, retrieved and placed the oral medication in the paper pill cup. EI # 9 entered the unsampled patient's room, verified the patient's armband and handed the patient the med cup and the water glass. At the patient's request, EI # 9 removed the bed sheets, assessed for edema in the thigh area, replaced the bedsheets, charted on her clipboard, exited the room and returned to the med room.

EI # 9 failed to perform hand hygiene after contact with the patient and the bedsheets.

During an interview on 4/24/14 at 10:15 AM, the above observations were confirmed by EI # 1.

Based on review of manufacturer equipment recommendations, observations and interviews, it was determined staff failed to follow facility policy and manufacturer recommendations for equipment disinfection and sterilization. This had the potential to negatively affect all patients served by the facility.


Findings include:

Endoscope Disinfection Guide

High-Level Disinfection...
...Drying
13. Use syringe to flush 70 % alcohol through air, water and suction channels. Inject air to remove retained alcohol..."


3M Attest 1262/1262P
Biological Indicator
Product Description:
"... The 3M Attest 1262 Biological Indicator ...is designed for monitoring steam sterilization processes.
The presence of...spores is detected by a visual color change. The yellow color indicates a sterilization process failure...

Monitoring Frequency: Attest biological indicators should be...used to monitor every load. This...improves the performance of the sterilization process.

Directions for Use:
1. Identify the Attest biological indicator by writing the sterilizer, load number, and processing date on the indicator label...
13. The appearance of a yellow color in the processed indicator demonstrates bacterial growth and a sterilization process failure. No color change indicates an adequate sterilization process. A final negative result is made after 48 hours of incubation. The positive control indicator should show a yellow color change for the processed indicator results to be valid. 14. Record the sterilized and control biological indicator results. Act on any positive test as soon as the first evidence of growth is noted. Always retest the sterilizer and do not use the sterilizer until the biological indicator results are negative..."


Facility Policy and Procedure
Date Revised 6/16/10
Subject: Hand Washing of Surgical Instruments

Purpose:
"...Instrument washing should be done with the greatest of care.
Policy:
"...4. Place in sinks in Central Sterile for soak.
5. Place in water at temperature of 125 degrees Fahrenheit and add Enzymatic cleaner and soak for at least 15 minutes..."


Enzymatic Detergent and Pre-soak

Manual Cleaning Directions
"...3. For instrument holding solution, use 1/2 ounce to 1 ounce to concentrated per gallon of water..."


During an observation of care on 4/23/14 at 8:40 AM, Employee Identifier (EI) # 10, Scrub Technician, performed high-level disinfection of a colonoscope. EI # 10 allowed the scope to soak for 45 minutes in the Metrocide Plus solution and rinsed the scope using clean water and a syringe for flushing of the channels. EI # 10 performed the leak test, dried and wiped down the scope with clean surgical towels. EI # 10 then carried the scope into operating room # 2 and placed the scope in a hanging position in the scope cabinet.

EI # 10 failed to inject 70 % alcohol through the scope channels during the drying process as per the manufacturer disinfection guide posted in the scope cleaning room.

During an interview with EI # 10 on 4/23/14 at 9:55 AM, it was confirmed the disinfection guide had not been followed.

A tour of the Central Sterile department on 4/23/14 at 8:55 AM and interview with EI # 10 reported staff used "3 to 4 squirts" of Medline Dual Enzymatic detergent and submerges the instruments in water and detergent solution during cleaning prior to steam sterilization. EI # 10 was unable to determine how much 1 squirt of detergent was equivalent to and the amount of water used in the sink. The sink was not marked and there was no measuring equipment available.

Review of the Enzymatic detergent instructions included the following: "...use 1/2 to 1 ounce concentrated solution to 1 gallon water..."

An interview conducted 4/23/14 at 9:00 AM with EI # 10 confirmed staff failed to measure the amount of Enzymatic detergent and the amount of water in the sink during surgical instrument cleaning.


A tour of the Central Sterile department on 4/23/14 at 10:05 AM and interview with EI # 10 revealed staff failed to document monitoring and results of the 3M Attest biological indicator on the "Steam Sterilizer Record Keeping Envelope" on the following dates:

2/27/14
3/10/14
3/12/14
3/18/14
3/19/14
4/11/14
4/14/14

There was no documentation of the sterilized and control biological indicator results for the above dates.

In a 4/24/14 8:30 AM interview with EI # 10, the findings were confirmed.

Based on review of policy and procedures, review of medical records and interview it was determined that the swing bed patients did not participate in an ongoing activities program. This affected 2 of 2 swing bed patients reviewed Medical Record (MR) # 3 and # 4 and had the potential to affect all patients admitted to the swing bed program.


Findings include:

Policy & Procedures: Activities

Purpose: To enhance maintenance or enhancement of each resident's quality of life.

Policy: It is the policy of Jackson Medical Center to provide an ongoing program of activities based on a comprehensive assessment. The goals of the activities are designed to meet the physical, mental and psychosocial well being of each patient.

Procedure:
" Activities are planned to meet the needs and interest of the patient...activities are provided in individual and group settings. The activity program includes a variety of activities including but not limited to reading, exercise, music, watching TV (Television), educational activities and social gathering. Each patient's activity plan shall be a part of the overall plan of care developed according to the patient's lifestyle, psychosocial evaluation and physician recommendation..."

Medical Record findings:

1. MR # 3 was admitted to the Swing Bed unit 4/18/14 with diagnoses of Left Great Toe Osteomyelitis and Insulin Dependent Diabetes Mellitus.

A review of the medical record included a form titled Nursing Rehabilitation. The top section of the form included rehabilitation activities:
" Passive range of motion
Active range of motion
Bed Mobility
Transfer
Walking
Dressing or grooming
Eating or swallowing..."

The bottom section of the form was titled Activities:
" Music
Reading
Cards
Watching TV
Crosswords
Arts/Crafts
Exercise
Socializing..."

The form was to be documented for the Day shift and the Night shift.

The Nursing Rehabilitation (Rehab) form dated 4/19/14 did not have any documentation under Nursing Rehab for the day or night shift.

The activities dated 4/19/14 did not have any documenation under the night shift and only contained one signature.

The Nursing Rehab form dated 4/20/14 did not have any documentation under Nursing Rehab for the day or night shift.

The Activities dated 4/20/14 did not have any documentation under the day or night shift, however it was signed by both staff for the date 4/20/14 and the night shift staff for 4/21/14.

The Nursing Rehab form dated 4/21/14 did not have any documentation under Nursing Rehab for the day or night shift.

The activities dated 4/21/14 did not have any documentation under the day or night shift and was not signed.

The Nursing Rehab form dated 4/22/14 did not have any documentation under Nursing Rehab for the day or night shift.

The activities dated 4/22/14 did not have any documentation under the day or night shift and was not signed.

The surveyor met MR # 3 on 4/23/14 to observe wound care and asked if he had participated in any activities. MR # 3 nodded to his bedside table and stated, " I got my dominoes here but nobody will play with me."

The staff were not addressing the needs of the patient related to activities.

2. MR # 4 was admitted to the Swing Bed unit 4/8/14 with a diagnosis of Status Post ORIF (Open Reduction and Internal Fixation) with hardware removal from left hip.

The Swing Bed Activities Assessment form documented the following list of activities the patient had a current interest in:
Music, reading, crosswords and socializing.

The section of the activity form documented, "Prefers to participate in activities:
> 6 times a week, 3-5 times a week, 1-2 times a week..." was not completed.

The Nursing Rehab form dated 4/8/14, 4/11/14, 4/12/14, 4/14/14, 4/15/14 and 4/16/14 did not have any documentation under Nursing Rehab for the day or night shift.

The activities dated 4/8/14, 4/11/14, 4/12/14, 4/14/14, 4/15/14 and 4/16/14 did not have any documentation under the day or night shift and was not signed.

The Nursing Rehab form dated 4/13/14 and 4/15/14 did not have any documentation under Nursing Rehab for the day shift or activities for the day shift.

The Nursing Rehab form dated 4/17/14, 4/18/14 and 4/20/14 did not have any documentation under Nursing Rehab for the night shift or activities for the day shift or night shift.

In an interview with Employee Identifier (EI) # 1, the Chief Administration Officer, on 4/24/14 at 9:30 AM, confirmed the above information

Based on review of medical records and interview it was determined that 1 of 1 patients receiving rehabilitative services on the Swing Bed unit failed to receive the Occupational Therapy (OT) services ordered. This affected Medical Record (MR) # 4 and had the potential to affect all patients served in the Swing Bed program.

Findings include:

1. MR # 4 was admitted to the Swing Bed unit 4/8/14 with a diagnosis of Status Post ORIF (Open Reduction and Internal Fixation) with hardware removal from left hip.

The physician orders on admission included orders for Physical Therapy and Occupational Therapy to evaluate and treat.

The OT evaluation was completed 4/16/14, 8 days after admit to the Swing Bed unit. The evaluation contained both short and long term goals and a frequency and duration of 2 to 3 times a week for 3 weeks.

The medical record failed to include any further visits by the OT.

In an interview with Employee Identifier (EI) # 5, the Nurse Manager, 4/23/14 at 2:30 PM, she confirmed OT only comes one time a week on Wednesdays. EI # 5 stated that OT did not usually have a frequency.

The patient failed to recieved the ordered care.

In an interview with EI # 1, the Chief Administration Officer, on 4/24/14 at 9:30 AM, confirmed the above information