HospitalInspections.org

Based on observations, review of medical records, review of policy and procedures, CDC (Centers for Disease Control) safe practices, Infection Control and interviews with facility staff, it was determined the Governing Body failed to ensure the hospital:

1. Maintained a safe environment for patient care.

2. Developed, implemented and maintained a quality assessment and performance improvement program to include all hospital departments.

3. Maintained an active infection control program to monitor, prevent and control infections.

4. Staff followed infection control policies to prevent potential infections and spread of potential infections.

5. Staff performed hand hygiene according to facility policy.

6. Provided a Social Worker to participate in patient assessment and treatment team planning in the Geriatric Psychiatric Unit.

7. Conducted Pharmacy and Therapeutics Committee meetings.

8. Was constructed, arranged and maintained to ensure patient safety.


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


Refer to A 063, A 144, A 263, A 308, A 392, A 492 A 700, A 747 and A 756 for additional findings.

Based on review of policy and procedure and interview it was determined the facility failed to provide social work services by a qualified Social Worker.

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

Findings include:

Hospital Policy and Procedure:
Southern Oaks Grove Hill Memorial Hospital Policy:
# 1-01 Program Narrative

" Scope of Services:
A. Program Definition
The unit is an organized service with designated qualified Mental Health Professionals that provide a regiment of 24-hour professionally directed evaluation, care and intensive treatment for psychiatric patients in a structured inpatient setting.

D. Staff Composition
The multidisciplinary team is central to the philosophy of staffing an inpatient hospital setting... The program is also staffed with a Medical Director, Program Director, Outreach Coordinator, Registered Nurses, Licensed Practical Nurses, Social Workers, Recreational Therapist, Professional Counselors and Mental Health Technicians..

IX Admission:
C. Psychosocial Assessment
1. The patient and family are interviewed by a Social Worker to assess the family's reaction to the illness and the patient's perception of his or her condition...
2. The Psychosocial Assessment, based on the identified needs of psychiatric patient is completed by the third treatment day by the Social Worker...

XI Multidisciplinary Treatment Planning:
E. Weekly interdisciplinary treatment planning meetings facilitate the development and implementation of the plan, as well reviewed the patients progress toward meeting their goals. At a minimum, the treatment team consists of the Psychiatrist, Social Worker, Recreational/Activity Therapist... and a Registered Nurse..."


During a tour of the GPU (Geriatric Psychiatric Unit) 7/29/14 at 12:15 PM the surveyor was accompanied by Employee Identifier (EI) # 8, GPU/ Outreach/ Assistant Director. During the tour the surveyor was introduced to EI # 31 the Social Worker. EI # 31 stated that she visited the unit one time a month to review and sign off on social worker issues.


In an interview 7/31/14 at 9:40 AM with EI # 9, the GPU Program Director, the staffing for the unit was reviewed.


EI # 9 informed the surveyor that EI # 8 was not a Social Worker but acted in an Outreach position assisting with discharge planning, communicated with families and the psychiatrist. The surveyor asked what EI # 8's back ground included. EI # 9 stated that she was educated as a recreational therapist but had let her certification/license lapse since she did not work in that area. EI # 9 stated that EI # 8 worked three days a week.

EI # 9 stated that the Social Worker, EI # 31, came twice a month and reviewed the paperwork completed by EI # 8 and signed off on the papers.

The Governing Body was not aware the policy was not followed to staff the GPU with a Social Worker to participate in the patient's assessment and development of treatment plans.

This condition level deficiency is cited based on observations, review of the medical records and the facility's policies and procedures and interview it was determined the facility failed to ensure the staff:

1. Followed the facility policy for use of Restraints.

2. Placed a newborn infant in the nursery to prevent potential harm from others in the immediate area and to protect the infant from possible infection control issues with patients in isolation.

This affected 1 of 1 patient's with a PRN (as needed) restraint order. This affected 1 of 1 newborn infant born 7/29/14. This had the potential to negatively affect all patients served by this facility.

Refer to A 144 and A 169 for additional findings.

Based on review of medical records, observation and interview the facility failed to ensure newborn infants were in a safe, secure and clean area.

This affected 1 of 1 newborn infants, Medical Record (MR) # 13.


During a tour of the Labor & Delivery (L & D) and Nursery Unit on 7/29/14 from 10:25 AM to 2:10 PM the surveyor observed two (2) entrance doors without locking mechanisms into the unit. One entrance was from the main lobby of the hospital and the other entrance was from the emergency room hallway.


At 1:19 PM on 7/29/14 the surveyor observed the birth of MR # 13 in L & D (Labor and Delivery) Room 124. Employee Identifier (EI) # 12, Licensed Practical Nurse (LPN) assigned to MR # 13 completed her newborn assessment and informed the surveyor she was taking MR # 13 to the mothers L & D Room then on to the assigned room on medical/surgical (med/surg) and postpartum.

At 3:11 PM, the surveyor observed MR # 13 lying in the isolette in the entrance to the nurses' station on the postpartum and medical/surgical unit which also provided care to patients requiring isolation. The surveyor asked EI # 13, the Unit Secretary, why the baby was at the nurses' station. EI # 13, stated, "I am waiting on the nurse to return from lunch and I am watching the baby until then". The surveyor asked, "Does that happen often?" EI # 13 replied, "Yes all the time".

From 3:11 PM to 3:29 PM the surveyor observed multiple staff touching and moving MR # 13's isolette from the nurse's station entrance to the connecting supply room entrance.

At 3:29 PM EI # 12 returned to the nurses' station and informed the surveyor she was taking EI # 13 to the nursery to be fed since the mother was not in her postpartum room.


The facility did not ensure MR # 13 was placed in the nursery to prevent potential harm from others in the immediate area and to protect the infant from possible infection control issues with patients in isolation.

During an interview on 7/31/14 at 11:48 AM with EI # 7, Administrator, confirmed that the security on L & D / OB was an ongoing issue.

Based on review of medical records, review of policy and procedures and interview the facility failed to followed the facility policy as related to PRN (as needed) orders for patients who had restraints ordered.


This affected and 1 of 1 patients with a restraint order, MR # 1. This had the potential to affect all patients served by this facility.

Policy and Procedure: Restraint/Seclusion

Policy:

" All patients have the right to be free from restraints that are not medically necessary or are used for purposes other than patient benefit and safety.
Restraints shall be used only where alternative methods are not sufficient to protect patients or others from injury and are not a substitute for less restrictive forms of protective restraints...

Supportive Data...Restraint for Acute Medical and Surgical Care:

The use of restraint must be:
(a)Selected only when other less restrictive measures have been found to be ineffective to protect the patient or others from harm.
(b) On accordance with the order of a physician or other licensed independent practitioner... The order must:
(1) Never be written as a standing order or on an as needed basis (PRN)..."

Medical Record Findings:

1. MR # 1 was admitted to the facility 1/16/14 with diagnoses of Alzheimer's Disease, PEG (Percutaneous Endoscopic Gastrostomy) tube incompetence, Dehydration, Sepsis and Multiple Decubitus Ulcers.

The admission orders included, "Restrain PRN."

The ChartLink Physician Entered Orders form documented on 1/16/14 at 17:32 (5:32 PM) orders:"Restrain PRN."

The ChartLink Physician Entered Orders form documented on 1/16/14 at 21:26 (9:26 PM) orders:"Restrain PRN."

The form reflects these two orders were electronically signed by the physician 3/21/14 at 1:29 PM.

In an interview 7/31/14 at 10:30 AM with Employee Identifier # 1, Registered Nurse Manager, confirmed they would have to "educate the doctors regarding restraint orders."

This condition level deficiency is cited based on observation and interview it was determined the Governing Body failed to:

Findings include:

1. Ensure all hospital departments participated in the QAPI program.

2. Ensure Newborn infants were in a safe, secure and clean area.

This affected Medical Record (MR) # 13 and had the potential to negatively affect all patients in this facility.

Refer to A 308 and A 309 for additional findings.

Based on a review of the Quality Assurance Performance Improvement (QAPI) program and interview, it was determined the governing body failed to ensure all hospital departments participated in the QAPI program.

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

Findings Include:

A review of the 2013 QAPI program was conducted on 7/31/14 at 9:15AM with Employee Identifier (EI) # 2, the Quality Improvement (QI) Manager.

Review of the QAPI qtrly (quarterly) reporting / attendance log revealed the facility had an overall 58 % (percent) reporting rate for 2013.

There were no QAPI qtrly reports documented for the Med/Surg (Medical/Surgical), GPU (Geriatric Psychiatric Unit), PO (Purchasing) and US (Ultrasound) Departments.

An interview was conducted on 7/31/14 at 10:00 AM with EI # 2 who verified the above findings.

Based on observation, review of the Quality Assurance Performance Improvement (QAPI) program, facility memorandum dated 5/16/13 and interview, it was determined the governing body failed to ensure:

a). Staff placed a newborn infant in the nursery to prevent potential harm from others in the immediate area and to protect the infant from possible infection control issues with patients in isolation.

b). All hospital departments participated in the annual evaluation of the QAPI program as directed per facility management.

This affected Medical Record (MR) # 13 and had the potential to negatively affect all patients in this facility.

Findings Include:

Memorandum:
To: Department Managers
...Da (Date): May 16, 2013
Re (Regarding): Annual P.I. (Performance Improvement) Review ...

1. Annual Review: The Annual Review of Performance Improvement activities for the past year is due on the day of the QA-PI committee meeting ...

..."The State" expects a hospital to demonstrate, with objective data, that improvements have taken place in actual care outcomes, processes of care, ... and other performance indicators. The Annual Review of your department's QA-PI activities will help serve as documentation ... The Annual Review is a requirement.


1. During a tour of the Labor & Delivery (L & D) and Nursery Unit on 7/29/14 from 10:25 AM to 2:10 PM the surveyor observed two (2) entrance doors without locking mechanisms into the unit. One entrance was from the main lobby of the hospital and the other entrance was from the emergency room hallway.

At 1:19 PM the surveyor observed the birth of MR # 13 in L & D Room 124.

At 3:11 PM, the surveyor observed MR # 13 lying in the isolette in the entrance to the nurses' station on the postpartum and medical/surgical unit which also provided care to patients requiring isolation. The surveyor asked Employee Identifier (EI) # 13, the Unit Secretary, why the baby was at the nurses' station. EI # 13 stated, "I am waiting on the nurse to return from lunch and I am watching the baby until then". The surveyor asked, "Does that happen often?" EI # 13 replied, "Yes all the time".

The facility did not ensure MR # 13 was placed in the nursery to prevent potential harm from others in the immediate area and to protect the infant from possible infection control issues with patients in isolation.

2. Review of the facilities Performance Improvement Committee Meeting Minutes for 2013 and 2014 read as follows:

"06-11-2013
IV. New Business
B. Safety:
2. Discussed results of OB (Obstetrical) department safety survey/walk-thru done May 29th by ..."

"08-06-2013
III. Old Business
E. L & D / OB Security: Quote x (times) 1 for keypads received. OB department survey done 05/29/13.
F. Cameras for L & D OB departments: Recommended during the survey. Ongoing."

"10-02-2013
III. Old Business
C. L & D / OB Security: Ongoing."

"01-08-2014
III. Old Business
B. L & D / OB Security: Ongoing. P. O. (Purchase Order) manager states that he is waiting on third quote for lock system."

"04-3-2014
III. Old Business
B. L & D / OB Security: Ongoing."

"06-04-2014
III. Old Business
B. L & D / OB Security: Ongoing."

There was no locking mechanism on the 2 entrance doors into the L & D / OB department on 7/29/14, 7/30/14 and 7/31/14.

During an interview on 7/31/14 at 9:15 AM with Employee Identifier (EI) # 2, the Quality Improvement (QI) Manager, confirmed this issued had been addressed in QAPI and was ongoing.

During an interview on 7/31/14 at 11:48 AM with EI # 7, Administrator, confirmed that the security on L & D / OB was an ongoing issue and had not been resolved since 5/29/13.

2. A review of the 2013 QAPI program was conducted on 7/31/14 at 9:15 AM with EI # 2, the QI Manager.

Review of the QAPI quarterly (qtrly) reporting / attendance log for 2013 revealed a total of 23 departments.

Review of the log revealed, "2-12-2014 Delinquent Annual Reviews (11 depts [departments])" for a total of 48 % (percent). The facility failed to have all departments participate in the Annual Review as directed per facility management.

An interview was conducted on 7/31/14 at 10:00 AM with EI # 2 who verified the above findings.

This Condition of Participation is not met as evidenced by:

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

1. Document wound measurements

2. Document specific wound care provided

3. Document wound assessments to include appearance of the wound/ wound bed, exudates, drainage, odor signs and symptoms of infection

4. Document education to caregiver or patient related to wound care after discharge

5. Have orders for wound care provided

6. Ensure nutritional assessment for the patients were completed

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

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


Findings include:

Refer to A 392 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. Document wound assessments to include appearance of the wound/ wound bed, exudates, drainage, odor signs and symptoms of infection

4. Document education to caregiver or patient related to wound care after discharge

5. Have orders for wound care provided

6. Ensure nutritional assessment for the patients were completed

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

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

This did affect MR # 1, # 2, # 3, # 4, # 11 and # 14, 6 of 6 wound care records reviewed.


Policy and Procedure:

Management of Pressure Ulcers # 9202

Policy: "... shall ensure that all patients admitted to this hospital receive a complete head to toe assessment, at which time a thorough examination of the skin will be done.

Any pressure ulcer present at the time of admission will be identified...

Procedure:
Management of Pressure Ulcers:
Nursing staff will take initial pictures if necessary and as needed, identify, date and mount for medical treatment of the patient.
Complete the Pressure Ulcer Assessment Form. Record the date and time of initial and subsequent treatment per physician's orders.
Call physician to report condition of pressure ulcer and for treatment orders...

Nursing Staff will:

Assess, reassess and document ulcer's characteristics.
Observe for infection...
Follow physician's orders for treatment of the pressure ulcer, including cleansing and dressing...
With each dressing change or at least weekly, the pressure ulcer wound will be assessed and documentation...:
Date, Location of ulcer and staging, Size (perpendicular measurement of the greatest extent of length and width of the ulceration, depth of the pressure ulcer wound...
Presence of exudates:
Type: purulent/serous, color, odor, amount, pain and wound bed... color and type of tissue/character, including evidence of healing (granulation tissue) or necrosis (slough or eschar).

Documentation:
Document interventions used to prevent the development of pressure ulcers. Pressure ulcer flowsheet documentation:
Date and time of initial and subsequent treatments.
Dressing changes. Size of the pressure ulcer (length, width and depth)..."


Policy and Procedure: Dressing Change- Surgical # 9154

" Policy: Standard precautions shall be followed when changing surgical dressings... A physician's order shall be obtained prior to changing the dressings...

Documentation: Date and time of dressing change, wound cleansing, wound assessment, type of dressing and tape applied and patient tolerance to the procedure..."

Policy and Procedures:
Guidelines for Isolation Precautions # 2011

" Contact Precautions:
These precautions are to be used to reduce the risk of transmission of resistant microorganisms by direct or indirect contact with a patient and/or patient's environment...
All PPE's (Personal Protective Equipment) should be removed and discarded appropriately in the patient's room before exiting... Hand hygiene should always be done before leaving the room either with soap and water or alcohol-based hand rub...
HCWs (Health Care Worker) should always explain the necessity of PPE's and expanded precautions to the patient and patient's family."


Medical Record findings:

1. MR # 1 was admitted to the facility 1/16/14 with diagnoses of Alzheimer's Disease, PEG (Percutaneous Endoscopic Gastrostomy) tube incompetence, Dehydration, Sepsis and Multiple Decubitus Ulcers.

The physician's orders on admission 1/16/14 at 3:15 PM included, "Wound care Decubiti- physical therapy evaluate and treat..."

The skilled nurse assessment/interview conducted 1/16/14 at 7:12 PM documented, "Decubitus Stage II coccyx/buttock, inner areas of right knee, left lower extremity, right heel."

Amended nurses note 1/16/14 at 7:24 PM documented, "Decubitus Stage II areas cleaned with NS (normal Saline) and covered with Xeroform gauze, ABD (abdominal) pads and secured with tape."

There were no orders for wound care to the decubitus at this time. The nurse failed to measure the wounds, assess them for purulent/serous drainage, color, odor, amount, pain and wound bed... color and type of tissue/character, including evidence of healing (granulation tissue) or necrosis (slough or eschar) as directed per facility policy.

On 1/17/14 at 9:32 AM the Physical Therapist (PT) evaluated the patient's wounds. The assessment included, "Pt (patient) with right sacral decubitus (Length x Width) 5.6 cm (centimeters) x 5.2 cm; stage II 100% granulation. Wound cleaned with sterile water and 4 x 4, sharp debridement of lower non-adherent necrotic tissue unremarkable. Wound dressed: debrided in sterile field. Dressed with Vaseline gauze, 4 x 4, telfa and cover all. 2nd wound left sacral (midline) (LxW) 0.8 cm x 0.7 cm stage II 100 % granulation. Wound clean with sterile water, 4 x 4 and dressed with hydrogel, 4 x 4, telfa and cover all. Nursing notified of wound measurements... at present patients wounds do not require skilled PT services and can be dressed and changed daily by nursing."

The therapist did not write an order for the wound care or document consultation with the physician about wound care orders.

On 1/17/14 at 1:55 PM the physician wrote an order as follows, "Dress decubiti with Xeroform gauze BID ( twice a day)."

The initial interview documented by the nurse 1/16/14 at 7:24 PM included, "Pt had PEG tube replaced per home health earlier today and foley catheter..."

The physician's orders were for tube feedings manual- Jevity 1.5 calorie (cal) 5 cans per day per peg tube.

The 1/16/14 at 9:30 PM nurses note documented, "Peg tube intact large amount of brown colored drainage noted pooled around site."

The 1/16/14 nurses note continued at 10:50 PM documented, "Peg tube checked for placement x 2 per auscultation and aspiration. No residual. 1 can of Jevity 1.5 cal formula given per PEG tube via gravity."

The 1/16/14 nurses note continued at 11:10 PM documented, "Peg tube noted leaking, looks like actual formula fed. Copious amount noted. Site cleansed with normal saline and 4 x 4's applied around tube."

There was no documentation the physician was notified of the leakage from the PEG tube.

The patient was admitted to the facility with a diagnosis of PEG tube incompetence and multiple decubitus. The facility staff failed to request a nutritional assessment or complete a nutritional screening with involvement of the Registered Dietitian.

In an interview with Employee Identifier (EI) # 29, Registered Dietitian, on 7/30/14 at 1:00 PM, EI # 29 confirmed she had not received any nutritional screenings or nutritional assessments since January 2014.

In an interview 7/31/14 at 10:30 AM with EI # 1, Registered Nurse Manager, confirmed the above information and that they had a lot of education to do with the staff.

2. MR # 3 was admitted to the facility 9/23/13 with Infiltrating Ductal Carcinoma of the Left Breast, Hypertension, Depression, Neuropathy and Hypothyroidism.

The patient underwent a Radical Mastectomy of the Left Breast 9/23/13.

On return from surgery 9/23/13 at 10:45 AM the nurse documented, "Noted 2 JP (Jackson Pratt) drains to left mastectomy site draining sanguineous fluid. Dressing and ace wrap intact to surgical site, clean and dry."

On 9/25/13 at 9:27 AM the nurse documented, "Dressing dry and intact, reinforced dressing, gauze dressing, dressing changed at 9:20 AM...Drainage/Exudate minimum, serosanguineous...patient was educated on dressing, wound care, wound inspection, and calling doctor of any signs of bleeding, worse pain or infection." The patient was discharged at 9:45 AM with daughter.

The discharge instructions documented education focused on treatments and wound care.

The medical record failed to have orders for wound care provided by the skilled nurse and failed to have orders for wound care that was instructed to the patient prior to discharge. The patient was discharged to home health and there is no documentation of any orders provided to the home health for wound care.

In an interview 7/31/14 at 10:35 AM with EI # 1, the above information was confirmed.

3. MR # 2 was admitted to the facility 8/15/13 with diagnoses of Altered Mental Status, Diabetes Mellitus Type II, Urinary Tract Infection, Dehydration and possible Gastrointestinal Bleed.

On the nurses physical assessment dated 8/16/13 at 8:45 AM the nurse documented, "Pressure wound location coccyx and right hip..."

The 8/16/13 note was amended 8/17/13 at 4:27 PM, "Patient has breakdown area on coccyx, right butt cheek and right thigh... see unisex body..."

The 8/16/13 unisex body sheet documented by the nurse, "Site A first observed 8/15/13 3 cm x 1/2 on the coccyx stage I pinkish in color, Site B right buttock first observed 8/15/13 6 cm x 2 cm area noted stage I and site C right thigh 2 cm stage I..."

On 8/19/13 an amended note was written at 10:22 AM, "Changed patient used hydroderm cream applied to coccyx, wound is pink..."

There were no orders for wound care to the decubitus at this time. The nurse failed to measure the wounds, assess them for purulent/serous drainage, color, odor, amount, pain and wound bed... color and type of tissue/character, including evidence of healing (granulation tissue) or necrosis (slough or eschar) as directed per the facility policy.

In an interview 7/31/14 at 10:40 AM with EI # 1, the above information was confirmed.

4. MR # 4 was admitted to the facility 9/12/13 with diagnoses of Carcinoma Left Breast, Hypertension and Arthritis.

The admission assessment included, "Lives by herself... plans to return home as before admission..."

The 9/12/13 assessment post op (operative) documented 9/12/13 at 9:30 AM, "Two Jackson-Pratt drains intact draining sanguineous drainage, dressing to left side intact, moderate amount of bright pink drainage noted to dressing near Jackson-Pratt drain insertion site lower left lateral aspect of surgery site..."

The discharge instructions education focus prior to discharge: Wound care.

The patient was discharged 9/13/13 to be followed by home health. The medical record failed to contain any wound care orders that the patient would have been instructed on and failed to document any wound care orders provided to home health. The patient was discharged the day after she had the mastectomy.

The admission orders included, "Arrange for visiting nurses to come daily- daily dressing changes and JP care (drain)..."

In an interview 7/31/14 at 10:45 AM with with EI # 1, the above information was confirmed.

5. MR # 11 was admitted to the facility 7/28/14 with diagnoses of Dementia Not Otherwise Specified, Delusions, Behavioral Disturbances, Shingles and Multiple Skin Tears.

The skilled nurse skin assessment documented 7/28/14 included 6 identified skin tears, 2 locations labeled as shingles and bruising in 5 different areas covering the body.

The admission orders from 7/28/14 failed to include any wound care orders, a Physical Therapy (PT) evaluation was ordered but not specified to evaluate wounds.

The nurse documented 7/29/14 at 6:30 AM, "Dressing changed to BLE (bilateral lower extremities), dressing was dried and stuck to wound, applied NS to bandage, gently removed old bandage, moderate amount of drainage on old bandage, no odor noted, wound cleaned with NS and covered with telfa and wrapped with kling and secured with paper tape, dressings to right upper arm changed, small amount of bleeding noted to wound, no odor noted, small telfa applied to wound and covered with kling secured with paper tape."

In an interview 7/30/14 at 8:05 AM with EI # 30, Registered Nurse, she was asked if she had orders for the wound care she provided 7/29/14. EI # 30 stated that she used her nursing skills and she knew the therapist would be assessing the patient.

The wounds were not measured 7/29/14 and the appearance of the wounds and drainage color was not documented as directed per the facility policy.

On 7/30/14 the nurse on the night shift documented, "Wound care per nursing services until evaluated by PT."

EI # 30 reported the nurse on the night shift 7/30/14 changed the dressings because the dressing on her chest had soaked through the dressing, her gown and onto the bed linens. The surveyor asked if the drainage was serosanguineous and EI # 30 stated, "No it was a large amount of greenish drainage."

The physician was not made aware of the large amount of green drainage from the wound. The nurse failed to document on her nurses note when she changed the dressing, why and any appearance of drainage.

The PT consultation in the medical record dated 7/30/14 documented, "Areas impacted by the shingles do not appear to require any skilled intervention and debridement, should do well with changing dressings out 2-3 times a day by nursing staff. Please see initial evaluation."

The PT did not comment on the numerous skin tears on the patient's legs and arms. No wound measurements were documented.

The nursing staff failed to document measurements, drainage color, amount, location wound bed... color and type of tissue/character, including evidence of healing (granulation tissue) or necrosis (slough or eschar).

The nurse provided wound care 7/29/14 at 6:30 AM without orders.

The nurse 7/30/14 failed to document what wound care she performed and to which location.

In an interview 7/31/14 at 9:40 AM with EI # 9, GPU (Geriatric Psychiatric Unit) Director confirmed the above information.

6. MR # 14 was admitted to the facility 7/29/14 with diagnoses of Cellulitis/ Abscess Arm and Diabetes Mellitus Type II, Hypertension and Renal Insufficiency.

The patient was placed on Contact Isolation on admission by nursing staff due to the draining abscess.

On 7/30/14 at 6:21 AM the nurse documented, "Pt bandage removed. Softball size abscess under right axillary. Large amount of purulent drainage noted. Redness and swelling also noted. Nurse from OR (operating room) came to transport pt to surgery."

On arrival at the facility 7/30/14 at 7:05 AM the surveyor observed MR # 14's room door standing open with the isolation bag hanging over the outside of the door. The bed was unoccupied and a female was sitting in the chair at the bedside.

A second observation of the room at 7:30 AM revealed the door was closed.

The patient was taken to surgery 7/30/14 for incision and drainage of the abscess of the right axilla. Cultures were obtained, the wound was irrigated with saline and packed with Iodoform gauze. The documented plan was to remove packing tomorrow and re-irrigate.

On 7/30/14 at 11:00 AM two small boys were observed running in the hallway, when asked where they were going they ran into MR # 14's room and left the door standing open, the boys did not observe the rules for isolation.

Approximately 10 minutes later the boys exited the room leaving the door standing open and MR # 14 was observed sleeping in the bed with siderails up.

The nurses failed to educate the patient and family members of the need for isolation. The nurse failed to ensure isolation policies were followed for the safety of the patient and the public.

In an interview 7/31/14 at 10:50 AM with EI # 1, she stated she did not know what to say regarding the observations.

Based on facility policy, documentation review and interviews, it was determined staff failed to:

1. Conduct Pharmacy and Therapeutics Committee meetings.

2. Manage and document the return of unusable drugs leaving the facility.

This had the potential to negatively affect all patients served.

Findings include:

Pharmacy Policy No. 01-02
Subject: Scope of Pharmacy Services
Review Date: 6/1/14

Policy
"The scope of pharmacy services...shall be adequate to meet the needs of patients and the medical staff...
Pharmacy and Therapeutics Activities
-Developing medication-related policies and procedures
-Participate in activities relating to review...evaluation of medication usage
-Participating...in establishing standards and protocols...

Pharmacy Areas of Responsibility
-Pharmacy (including dispensing, storage, and preparation areas)
-Medication storage in patient care areas (e.g., including nursing units and all areas where medications are stored or administered)...
-Medication storage refrigerators..."


Pharmacy Policy No. 18-09
Subject: Unusable Medications and Devices
Review Date: 6/2/14

Policy
" Unusable medications and devices shall be disposed of in accordance with this policy.

...Unusable medications and devices include those that are:
-Expired (outdated)
...Mislabeled (improper, illegible, missing, or worn)

Unusable medications...that are returnable to the source of supply...shall be segregated and held until returns are effected...out dated medications will be returned using EXP Pharmaceuticals Corp, a vendor servicing hospital out of date medications."


On 7/30/14 at 9:30 AM, a tour of hospital pharmacy services and interview with Employee Identifier (EI) # 10, the Pharmacist was performed.

EI # 10 reported to the surveyor the Pharmacy and Therapeutics Committee meets "every other month during the Medical staff meeting" and had in the recent "past met quarterly". EI # 10 reported to the surveyor the Pharmacy and Therapeutics Committee meeting minutes were kept in the Medical Staff meeting minutes.

EI # 10 explained to the surveyor the process of how drugs at the facility were destroyed. EI # 10 reported all medications including controlled substances and Class II drugs are returned to the contractor who comes in on an as needed basis, picks up and documents the medications being removed from the facility.

The surveyor asked EI # 10 to review documentation of the drugs returned to the contractor over the past year. EI # 10 then called EI # 11, Pharmacy Director. EI # 10 reported to the surveyor the documentation was kept in the business office.

On 7/30/14 at 2:20 PM an interview with EI # 10 was performed. EI # 10 confirmed there was no documentation of drug removal from the facility.

On 7/30/14 at 3:50 PM the surveyor requested the Medical Staff meeting minutes for 2013 and 2014 from EI # 7, Administrator.

On 7/31/14 at 7:00 AM, the surveyor met with the Pharmacy Director, EI # 11, and requested the facility policy for the Pharmacy and Therapeutics Committee.

Review of July 2013 to January 2014 Medical Staff meeting minutes documentation did not include the presence of a Pharmacist or Pharmacy Director. The meeting agendas did not include Pharmacy and Therapeutics Activities. There was no documented discussion of pharmaceutical services.

Review of the 2014 February Medical Staff meeting minutes documentation did include the presence of EI # 10, the Pharmacist. The meeting agenda did not include Pharmacy and Therapeutics Activities. There was no documented discussion of pharmaceutical services.

Review of the 2014 April Medical Staff meeting minutes documentation did not include the presence of a Pharmacist. The meeting agenda did not include Pharmacy and Therapeutics Activities. There was no documented discussion of pharmaceutical services.

Review of the 2014 June Medical Staff meeting minutes documentation did include the presence of EI # 10. The meeting agenda did not include Pharmacy and Therapeutics Activities. There was no documented discussion of pharmaceutical services.

There was no documentation Pharmacy and Therapeutics Committee meetings had been conducted for 2013 and 2014.

On 7/31/14 at 7:50 AM, EI # 7, the Administrator confirmed the above.

Based on observation, policy and procedures and interviews with facility staff it was determined the facility failed to ensure:

1. All medications and biological's available for patients were not expired.

2. All multi-dose vials were labeled per facility policy and included the date opened.

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

Findings include:

Pharmacy Policy No. 01-02
Subject: Scope of Pharmacy Services
Review Date: 6/2/14

Policy
"The scope of pharmacy services...shall be adequate to meet the needs of patients and the medical staff...

Pharmacy Specific Activities
-Selection, procurement and storage of medications...
-Preparing/dispensing (including labeling) of medications...
-Supervising all medication storage and preparation areas within the pharmacy throughout the facility...

Pharmacy Areas of Responsibility
-Pharmacy (including dispensing, storage, and preparation areas)
-Medication storage in patient care areas (e.g., including nursing units and all areas where medications are stored or administered)...
-Medication storage refrigerators..."

Pharmacy Policy No. 09-03
Subject: Medication Management-Storage

"...Policy
Expiration dates for medications shall be assigned according to this policy.

Expiration Dates for prepackaged products
Expiration dates shall be assigned to all prepackaged products...In no case shall the assigned date exceed the manufacturer's expiration date.

Expiration Date Monitoring
The expiration dates of all medications and devices shall be checked...by the pharmacy...Expiration dates of medications and devices shall be checked during routine medication area inspections...scheduled to expire during the next month shall be removed from stock.

Expiration Dates Multiple Dose Vials
All multiple dose vials will be assigned an expiration date of 28 days from the date of the first dose. The date of expiration will be written on the bottle or stickers...placed on the bottle. This expiration date assignment will include...refrigerated items...."


Pharmacy Policy No. 5039
Subject: Opening/Dating Sterile Vials
(No Review Date)

Policy
"...sterile items for parental use shall be discarded after a specific length of time after opening...
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)..."


Pharmacy Policy No. 11-05
Subject: Dispensing: Labels
Review Date: 6/2/14

Policy
All medications ...shall be clearly, accurately, appropriately, and safely labeled using a standardized method.

...Label Contents
All labels shall include at least:
-Medication name, strength, form and amount...
-Expiration date when not used within 24 hours
-Expiration time when the expiration is less than 24 hours..."

Policy for Expired Supplies
(No number or date)

"All expired supplies are returned to the Central Supply Area or Pharmacy according to the item...All IV fluids...are donated..."


Pharmacy Policy No. 18-09
Subject: Unusable Medications and Devices
Review Date: 6/2/14

Policy
Unusable medications and devices shall be disposed of in accordance with this policy.

...Unusable medications and devices include those that are:
-Expired (outdated)
...Mislabeled (improper, illegible, missing, or worn)


1. An observation was conducted in the Medical unit on 7/29/14 at 10:20 AM with Employee Identifier (EI) # 10, Pharmacist and EI # 1, Registered Nurse (RN), Nurse Manager. The surveyor observed the following expired drugs or unlabeled drugs:

Medication Room:
7 bags of Dextrose 5 % with Potassium Chloride 40 milliequivalent (mEq) 1000 (milliliters) ml expired 3/2014

1 Nubian multi-dose vial opened and not labeled

1 bag of Dextrose 5% with Potassium Chloride 40 mEq expired 3/2013
1 bag of Magnesium Sulfate 4 grams in 50 ml sterile water expired 5/2013
4 100 ml bags of Dextrose 5 % expired 6/2014
1 Lidocaine 1% 30 ml vial, opened and not labeled
Lorazepam 0.5 mg (milligrams) 21 tablets expired 11/2013
Librium 25 mg 10 tablets expired 6/2013
Diphenoxylate/Atropine 25/0.025 mg 28 tablets expired 5/2014
Valium 5 mg ½ tablet expired 4/14
Chlorazepate 3.75 mg 20 tablets expired 8/2012
Hydrocodone 5 mg/APAP (Acetaminophen) 325 mg 12 tablets, open and not labeled
Norco 5 mg 15 tablets, open and not labeled
Nalbuphine Hydrochloride injectable 20 mg/ml expired 6/2014, open and not labeled
Promethazine syrup 6.25 mg/5 ml, 4 ounces expired 12/2013
Metoclopramide 5 mg/5 ml 16 ounces, expired 11/2013, open and not labeled
Geritol 4 ounces expired 5/2014
Docusate Sodium syrup 20 mg/5 ml, 16 ounces expired 11/2013
Ferrous Sulfate Elixir 16 ounces expired 12/2013
1 bottle sterile water, open and not labeled
Humulin N U-100 10 ml open and not labeled
Novolog 70/30 10 ml open and not labeled
Methylergonovine Maleate 0.2 mg/ml 1 ml 5 ampoules expired 6/2014.

An interview with EI # 1 and EI # 10 at 10:50 AM on 7/29/14 confirmed the above findings.

2. During a 7/30/14 at 9:20 AM tour of the Pharmacy with EI # 10, the Pharmacist, the following expired and or not labeled medications were identified:
Five Humalog Mix 75/25 Kwik Pen, 3 ml (milliliter) pens expired 1/2014
One bottle Humulin N 3 ml expired 3/2014
One 0.5 ml dose of Measles, Mumps and Rubella vaccine expired 1/18/14
Twenty Pediatric 8.4 % Sodium Bicarbonate (inj) injectable 10 mEq (milliequivalent) expired 10/13
Twenty vials of Vancomycin Hydrochloride (HCL) inj 500 milligrams (mg) expired 7/2013
One hundred Pramipexole Dihydrochloride 0.5 mg tabs expired 11/2013
One 120 ml bottle of Ranitidine HCL 75 mg/5 ml, open and not labeled
One plastic baggie with 8 green tablets, hand written on baggie, Synthroid 88 mcq (microgram) expired 6/2013.

An interview with EI # 10 at 10:45 AM on 7/30/14 confirmed the above findings.


3. A 7/30/14 3:05 PM tour of Radiology department was performed with Employee Identifier (EI) # 22, Radiology Department Manager.
The following expired and/or not labeled medications were identified:
One 450 ml bottle of Readi-Cat 2 barium sulfate suspension was 2/3 empty, open and not labeled.

During the tour, EI # 22 discarded the solution and confirmed the finding.


18259


4. During a tour of the Emergency Room (ER) 7/29/14 at 9:45 AM, the following expired drugs were identified:

Ipratropium 0.02% ampoules 5 expired 3/14
3 expired 6/14
5 expired 11/13.

Ipratropium 0.5% ampoules 5 expired 6/14
3 expired 11/13.

Nitrolinqual Spray opened 4/6/14 on an opened shelf in the ER room. The medications were not removed after 28 days of being opened by the staff.

Nitroglycerin Tablets 1/150 grain tablets in an open bottle on the open shelf in the ER room with no labeled date of when the bottle was opened.

In an interview with Employee Indentifer (EI) # 6, the ER Nurse Manager, on 7/29/14 at 10:00 AM the above was confirmed.


28327


5. A tour of the Obstetrical Unit was conducted by the surveyor 7/29/14 at 10:25 AM with EI # 21, the Director of Nursing. The surveyor observed the following expired drugs or unlabeled drugs:

Nursery Refrigerator:
Famotidine Injection 200 mg / ml x (times) 1 vial: opened and not dated; expired 5/13.

In an interview 7/29/14 at 10: 25 AM, the above observations were confirmed by EI # 21, DON.

6. An observation was conducted in the surgery department on 7/30/14 at 7:24 AM with EI # 3, Operation Room (OR) Manager. The surveyor observed the following expired drugs or unlabeled drugs:

Procedure Room:
Glycopyrrolate 4 mg / 20 ml injection x 1: opened and dated 4/7/14

OR Hallway
Furosemide 40 mg / 4ml x 2 expired 7/4/14

OR # 1 Anesthesia Cart
Lidocaine Hydrochloride (HCL) 1 % injection 30 ml vial: opened and not dated
Succinylcholine 200 mg injection 20 mg / ml: opened and not dated
Labetalol Hydrochloride injection 100 mg / 20 ml: opened and not dated

In an interview 7/30/14 at 11:40 AM, the above observations were confirmed by EI # 3, OR Manager.

Based on observations during a 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.
Refer to A 701 for additional findings.

Based on review of equipment, observations and interview it was determined the facility failed to maintain preventive maintenance (PM) on the equipment in the hospital. This had the potential to affect all patients served.

Findings include:

A tour of the Emergency department (ED) was conducted by the surveyor 7/29/14 at 9:40 AM with Employee Identifier (EI) # 6, the ED Nurse Manager. The surveyor noted:

1. An Otoscope with a maintenance sticker due for preventive maintenance 6/2014 equipment in the emergency room.
2. SigmaSpectrum Intravenous Pump with no PM sticker in the emergency room.


A tour of the Kitchen was conducted by the surveyor 7/29/14 at 2:30 PM with EI # 25, the Dietary Manager. The surveyor noted:

1. Energy Star cooler with no PM sticker.
2. Steam table with no PM sticker.
3. 2 freezers with no PM sticker.
4. Ice machine with no PM sticker.
5. Dishwasher with no PM sticker.

The Plant Manager, EI # 26 came to the Kitchen during the tour and confirmed that no equipment in the kitchen had been observed for PM.

In an interview with EI # 26 at 11:30 AM on 7/29/14 stated all electrical equipment was to be checked for preventive maintenance.



28327

A tour of the Obstetrical Unit was conducted by the surveyor 7/29/14 at 10:25 AM with EI # 21, the Director of Nursing (DON). The surveyor noted the following equipment with no preventive maintenance stickers:

Nursery
1 Welch Allyn Thermometer
1pulse oximeter
1 infant scale

In an interview 7/29/14 at 10: 25 AM, the above observations were confirmed by EI # 21, DON.

A tour of the Surgery Department was conducted by the surveyor on 7/30/14 at 8:15 Am with EI # 3, OR (Operation Room) Manager. The surveyor noted the following equipment with no preventive maintenance stickers:

Preoperative (Pre-Op) Room
1 Welch Allyn Thermometer

Operating Room (OR) Hallway
1 Welch Allyn Thermometer

Post Anesthesia Care Unit (PACU)
2 Welch Allyn Thermometer

In an interview 7/30/14 at 11:40 AM, the above observations were confirmed by EI # 3, OR Manager.



30952


A tour of the Medical floor was conducted by the surveyor 7/28/14 at 9:50 AM. The surveyor noted the following equipment on the medical floor with no preventive maintenance stickers:

1 Scale-Tronix bed scales
2 Invacare 9805P hoyer lifts

In an interview 7/31/14 at 7:25 AM, the above observations were confirmed by Registered Nurse (RN), Employee Identifier (EI) # 16.


A tour of the Physical Therapy unit was conducted by the surveyor 7/29/14 at 12:45 PM with Employee Identifier (EI) # 14, Licensed Physical Therapist Assistant and EI # 15, Physical Therapy Aide. The surveyor noted the following equipment with expired or no preventive maintenance stickers :

1. 1 hydrocollator-preventive maintenance due 6/13
1 Dr. (doctor) Scholl's paraffin bath-preventive maintenance due 6/13
1 Nautilus NS-200 home gym (pulley set)- no preventive maintenance found
1 Dynatronics Dynatron 125 (ultrasound)-preventive maintenance due 6/13
1 CPS Forte US (ultrasound)- preventive maintenance due 6/13

An interview on 7/30/14 at 1:50 PM with EI # 17, HealthActions Human Resource Director, confirmed the findings.


A 7/30/14 at 11:15 AM tour of the Respiratory department was conducted by the surveyor. One TBird Avis III ventilator was found in the emergency ED) department trauma room. The preventive maintenance sticker revealed the ventilator was last inspected 6/13/14, next due 6/14.

EI # 6, Registered Nurse, ED Manager confirmed the ventilator's annual equipment inspection was overdue on 7/30/14 at 11:20 AM.

Based on observation, review of facility policy and interview with facility staff it was determined the facility failed to ensure supplies available for patient use were not expired.

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

Findings include:

Policy for Expired Supplies
(No number or date)

"All expired supplies are returned to the Central Supply Area or Pharmacy according to the item...All IV fluids...are donated..."

1. A tour of the Obstetrical Unit was conducted by the surveyor 7/29/14 at 10:25 AM with Employee Identifier (EI) # 21, the Director of Nursing. The surveyor observed the following expired supplies:

Nursery Crash Cart:
Suction connection tubing x (times) 1 expired 2/04

In an interview 7/29/14 at 10: 25 AM, the above observations were confirmed by EI # 21, DON.

2. An observation was conducted in the surgery department on 7/30/14 at 7:24 AM with EI # 3, Operation Room (OR) Manager. The surveyor observed the following expired supplies:

Procedure Room
BD Spinal Needle 25 gauge (ga) x 6 expired 7/13
Jelco 22 g 1" (inch) x 2 expired 6/13
Sterile Water for Irrigation 1000 cc (cubic centimeters) x 1 bottle: opened and dated 7/5/14
Sterile Water for Irrigation 500 cc x 1 bottle: /11/14 opened and dated 7/11/14
Providone Iodine Scrub 4 fluid ounce bottle: x 1 opened and not dated
Providone Iodine Scrub 4 fluid ounce bottle: x 1 opened and not dated; expired 6/14
Providone Iodine Scrub 4 fluid ounce bottle: x 1 expired 6/13
Plain Packing strip x 1 bottle expired 10/11

Preoperative (Pre - Op) Room
Jelco 18 gauge (ga) 1 - 1 1/4" (inch) x 1 expired 11/13
Jelco 18 ga 1 - 1 1/4" x 14 expired 4/14

Central Sterile
2-0 Chromic Gut Suture x 1 box expired 7/12
2-0 Chromic Gut Suture x 1 box expired 1/13
5-0 Coated Vicryl x 1 box expired 1/11

Operating (OR) Hallway
O - Chromic Gut x 1 box expired 7/10
1 - Chromic Gut x 1 box expired 1/14
4 - 0 Polysorb x 1 box expired 12/06

Malignant Hyperthermia Supply Cart
Red Top Laboratory (Lab) Tubes x 2 expired 1/14
Green Top Lab Tube x 1 expired 9/13
Blue Top Lab Tube x 1 expired 9/13
Purple Top Lab Tube x 1 expired 5/14
Gray Top Lab Tubes X 3 expired 12/10

OR # 1
LMA Unique size 2: opened and expired 7/28/14
0 Chromic Gut x 3 expired 1/13
0 Chromic Gut x 1 expired 7/13
1 Chromic Gut x 2 expired 2/13
4 - 0 Chromic Gut x 1 expired 7/10 and x 1 expired 1/14
2 - 0 Silk x 1 expired 1/14
6 - 0 Ethilon x 1 expired 7/13
Bone wax x 1 expired 1/12

In an interview 7/30/14 at 11:40 AM, the above observations were confirmed by EI # 3, OR Manager.


30952

A tour of the Medical floor was conducted by the surveyor 7/29/14 at 10:15 AM with EI # 28, Registered Nurse (RN), Charge Nurse. The surveyor observed the following expired supplies:

Pediatric Crash Cart:
Pediatric defibrillator pads, 1 pack of "Pedi-Padz" expired 8/2013

In an interview 7/29/14 at 10:20 AM, the above observation were confirmed by EI # 28.

On 7/29/14 at 12:40 PM a tour of supply room on the Medical Floor was conducted with EI # 1, RN, Nurse Manager. The surveyor observed the following expired supplies:

1 Multi-Lumen Central Venous Catherization Kit, expiration date 12/2012

In an interview 7/29/14 at 12:45 PM, the above observation were confirmed by EI # 1.


During a tour of the Physical Therapy department on 7/29/14 at 12:30 PM, the following supplies were found expired:
Coloplast Prep Protective Skin Barrier expired 10/2011
One 4 ounce bottle of Skin Prep expired 8/2011.

During a 7/30/14 1:25 PM interview with EI # 17, HealthActions Human Resource Director, confirmed the above findings.

Based on review of facility policy, Operating Room (OR) Log reviews and interviews with staff, it was determined the staff failed to monitor the temperature and humidity as directed per the facility policy in the surgery department and refrigerator temperatures throughout the facility. This had the potential to negatively affect all patients at this facility.

Findings Include:

Facility Policy: Monitoring Temperature and Humidity in the Operating Room/Procedure Room
Effective: 11/17/11

Procedure:
"The operating room circulator will monitor and record the temperature and humidity levels in the operating room and the procedure room on the days that the rooms are in use."

1. A review on 7/30/14 at 10:45 AM of the Temperature and Humidity Logs and the OR Log Book for April, May, June and July 2014 revealed the following date's cases were performed and there was no documentation of the Temperature and Humidity level on the log book:

OR # 1
4/7/14
4/24/14
4/25/14
5/1/14
6/22/14
6/27/14
7/3/14

Procedure Room
4/7/14
4/24/14
4/25/14
5/1/14
6/6/14
6/11/14
6/12/14
6/26/14
6/27/14
6/30/14

In an interview 7/30/14 at 11:40 AM, the above findings were confirmed by Employee Identifier (EI) # 3, OR Manager.

2. A tour of the Obstetrical Unit was conducted by the surveyor 7/29/14 at 10:25 AM with EI # 21, the Director of Nursing (DON). The medication refrigerator temperature log documentation failed to include monitoring since 7/17/14 for a total of 12 days.

In an interview 7/29/14 at 10: 25 AM, the above finding was confirmed by EI # 21, DON.



18259

A 7/29/14 12:15 PM tour of the Geriatric Psychiatric Unit (GPU) with (EI) # 8, GPU/Outreach/SW(social worker), was conducted. The dining room/activity room refrigerator temperature log documentation failed to include temperature monitoring daily for the refrigerator and had no monitoring of temperatures for the freezer.
A Refrigerator Cleaning and Temperature/ Microwave Cleaning sheet was attached to the side of the refrigerator.
The following dates were recorded with a temperature:
4/2/14, 4/11/14, 4/17/14, 5/27/14 and 5/31/14.
There was 27 days in April 2014 the temperatures were not checked and recorded.
There was 29 days in May 2014 the temperatures were not checked and recorded.
EI # 8 was unable to provide proof of any other temperatures being monitored.
A review of the Kitchen's Refrigerator Cleaning and Temperature/ Microwave Cleaning sheet was conducted by the Registered Dietitian, EI # 29, and recorded in her monthly reports.
The following dates were recorded with a temperature:
11/12/13, 11/15/13, 11/17/13, 11/19/13, 11/21/13, 12/7/13, 12/9/13 12/13/13, 12/14/13 and 1/10/14.
There was 25 days in November 2013 the temperatures were not checked and recorded.
There was 27 days in December 2013 the temperatures were not checked and recorded.
There was 30 days in January 2014 the temperatures were not checked and recorded.
The following dates were recorded with a temperature:
2/12/14, 2/15/14, 2/16/14, 2/19/14, 2/22/14, 2/23/14, 2/25/14.
There was 21 days in February 2014 the temperatures were not checked and recorded.
The following dates were recorded with a temperature:
3/1/14, 3/3/14, 3/4/14, 3/5/14, 3/6/14, 3/7/14, 3/8/14, 3/9/14, 3/13/14, 3/16/14, 3/17/14, 3/18/14.
There was 19 days in March 2014 the temperatures were not checked and recorded.
The following dates were recorded with a temperature:
4/18/14, 4/23/14, 4/24/14.
There was 27 days in April 2014 the temperatures were not checked and recorded
The following dates were recorded with a temperature:
5/3/14, 5/12/14, 5/17/14, 5/18/14 and 5/22/14.
There was 26 days in April 2014 the temperatures were not checked and recorded.
In an interview 7/30/14 at 1:00 PM with EI # 29, the Registered Dietitian confirmed the refrigerators temperatures had not been regularly checked and she had reported it in her monthly reports to the Dietary manager, EI # 25.






30952

A 7/29/14 10:20 tour of the Medical floor with (EI) # 1, Registered Nurse (RN), Nurse Manager, was conducted. The medication room refrigerator temperature log documentation failed to include monitoring on 7/5/14 and 7/20/14. During the tour, EI # 1 confirmed staff failed to document temperature monitoring for 2 days in July.

On 7/29/14 at 12:40 PM during the tour of the Medical floor with EI # 1, the surveyor requested to review the refrigerator temperature log documentation which held the patient nourishments, milk, juice, ice cream and popsicles. While on the tour, EI # 1 confirmed staff had failed to monitor the temperature of the nourishment refrigerator. There was no temperature monitoring documentation for review available.
A tour on 7/29/14 at 12:45 PM with Employee Identifier (EI) # 14, Licensed Physical Therapist Assistant and EI # 15, Physical Therapy Aide of the Physical Therapy unit was conducted. The surveyor observed the ice pack refrigerator with an excessive amount of ice in the freezer compartment and in need of defrosting.

An interview on 7/30/14 at 1:50 PM with EI # 17, HealthActions Human Resource Director, confirmed the finding.

This condition level deficiency is cited based on observations, review of facility policy and procedure, review of Infection Control Committee Minutes and interviews, it was determined the facility staff failed to:

1. Perform hand hygiene according to facility policy.

2. Maintain and clean equipment to prevent potential infection to patients and/or staff by use.

3. Follow policies and procedures for contact isolation.

4. Address problems identified by the infection control committee and take corrective action.

Refer to A 749 and A 756 for additional findings.

Based on observations, review of facility policy and procedure, the manufacturers instructions for disinfectant use, ACCU-CHEK Inform II Operator's Manual, and interviews, it was determined the facility staff failed to:

1. Perform hand hygiene according to facility policy.

2. Maintain and clean equipment to prevent potential infection to patients and/or staff by use.

3. Follow policies and procedures for contact isolation.


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


Policy Reference # 4003
Subject: Hand Hygiene-CDC (Centers for Disease Control)
Effective 6/8/19

Purpose:
" To provide guideline for effective hand hygiene...to prevent the transmission of bacteria, germs and infections.
Policy:
All personnel will use hand-hygiene techniques...the CDC has recommended...
Before each patient encounter
Before applying gloves and inserting...peripheral vascular catheters, other invasive devices that do not require a surgical procedure
After coming in contact with patient's intact skin...
After coming in contact with ...body fluids, dressings...
A

Procedure:
...If hands are not visible soiled, use an alcohol-based hand rub for decontaminating hands...Examples:
Before direct contact with a patient's intact skin (taking a pulse or blood pressure...
Before donning gloves to insert invasive devices...
After contact with medical equipment/supplies in patient areas
Always after removing gloves
Leaving an isolation area..."



ACCU-ChEK Inform II Quick Reference Guide Version I
Refer to the operator's manual for the proper cleaning and disinfection instructions for this system. · For multiple patient use, the meter should be cleaned and disinfected between each patient use following standard precautions and the cleaning and disinfecting procedures found in the ACCU-CHEK Inform II Operator's Manual.


Virex TB Disinfectant Cleaner

" Ready-to-use quaternary-based, hospital-grade disinfectant provides excellent cleaning and deodorizing action in one easy step...
· Quaternary-based, hospital-grade disinfectant that cleans and deodorizes.
· Disinfects in three minutes.
· Bactericide, tuberculocide, virucide, fungicide.
· Meets bloodborne pathogen standards for decontaminating blood and bodily fluids."

During a tour of the Physical Therapy unit on 7/29/14 at 12:30 PM, the surveyor observed 2 clear 22 ounce plastic bottles that contained a clear liquid solution labeled " cleanser " in the unit.
The surveyor asked Employee Identifier (EI) # 15, Physical Therapy Aide and EI # 14, LPTA, (Licensed Physical Therapy Assistant) what type of cleanser was in the bottles? EI # 15 handed the surveyor a bottle of Virex Tb disinfectant and reported she/he added 2 capfuls of Virex Tb to the bottle of water because it had a strong odor. The surveyor read the instructions for use on the Virex Tb disinfectant. There were no instructions to dilute the Virex Tb disinfectant.

During a 7/30/14 1:25 PM interview with EI # 17, HealthActions Human Resource Director confirmed staff failed to use the Virex Tb as directed.

On 7/29/14 at 2:15 PM, the surveyor observed Employee Identifier (EI) # 20, Licensed Practical Nurse (LPN) perform a medication pass. EI # 20 was documenting on his/her computer outside the nurse station, then entered the medication room. EI # 20 opened the medication drawer and placed 2 tablets in a medication cup. EI # 20 entered the patient ' s room and administered the 2 medications to the patient. EI # 20 then exited the patient room with the computer cart, went back to the medication room and replaced a medication bottle in the medication drawer. EI # 20 failed to perform hand hygiene prior to medication preparation and administration and before and after patient care.

At 2:25 PM on 7/29/14, EI # 19, RN, entered the medication room. EI # 19 retrieved a vial of intravenous (IV) Rocephin 1 gram and reconstituted the Rocephin with 50 milliliters of normal saline. EI # 19 exited the medication room and verified the medication with the computerized physician orders. EI # 19 failed to perform hand hygiene prior to reconstitution of the IV medication.
On 7/29/14 at 2:30 PM, EI # 19 entered the patient ' s room, verified the patient and medication via scanning, then exited the patients room and obtained an extension tubing for the IV medication administration. EI # 19 then prepared and began administration of the IV Rocephin via the infusion pump at 100 ml per hour. EI # 19 then exited the patients room. EI # 19 failed to perform hand hygiene after contact with the patient and the IV equipment.

On 7/29/14 at 2:38 PM, EI # 19 entered the medication room, obtained and prepared IV Flagyl 500 mg (milligrams) and exited the medication room. EI # 19 failed to perform hand hygiene prior to medication preparation.

EI # 19 entered the patient 's room, verified the patient and medication and assessed for the IV site. The patient 's IV had previously infiltrated and no IV access site was available. EI # 19 exited the patient room and verified computerized medication orders at the nurse station. EI # 19 phoned and spoke with the physician.

EI # 19 exited the nurse station, entered the medication room and retrieved a box containing IV supplies.

EI # 19 returned to the patient 's room, opened the IV start kit, applied the tourniquet and prepped the IV site with an alcohol prep pad. EI # 19 opened the tubing package and primed the extension tubing. EI # 19 donned gloves and unsuccessfully attempted to start the IV. EI # 19 placed a gauze dressing on the site. EI # 19 removed and discarded the gloves, gathered the IV box and computer chart cart and exited the room. EI # 19 entered the nurse station and again phoned the physician. EI # 19 failed to perform hand hygiene prior to donning gloves and after removing gloves during an invasive procedure.

A medication pass observation was performed on 7/30/14 at 8:30 AM with EI # 12, LPN. There was a sign on the door for use of Contact Precautions, gown and gloves required. EI # 12 donned gown and gloves and entered the patient ' s room with the chart cart and glucometer. EI # 12 failed to perform hand hygiene before donning gloves.

EI # 12 administered 4 po (oral) medications and performed a blood glucose test. EI # 12 exited the room, removed gown and gloves and placed them in a red biohazard bag. EI # 12 cleansed his/her hands with hand sanitizer, then pushed the chart cart down the hall to the soiled utility room. EI # 12 discarded the red bag in the soiled utility room. EI # 12 asked a housekeeping employee to wipe the glucometer with Clorox Cleanup wipe. EI # 12 removed the gloves and gown after leaving the patients room, failed to perform hand hygiene after disposal of the biohazard bag. The chart cart was not disinfected after leaving the room with Contact Precautions in use.

At 8:50 AM on 7/30/14 EI # 12 performed a blood glucose test using a glucometer, then removed gloves. Holding the dirty gloves in one hand, EI # 12 documented on the computer. EI # 12 then performed hand hygiene at the sink, exited the room and returned the glucometer to the holding station. EI # 12 failed to disinfect the glucometer after patient use and perform hand hygiene immediately after removing gloves.

During an interview on 7/31/14 at 10:30 AM with EI # 1, RN (Registered Nurse), Nurse Manager confirmed staff failed to follow facility infection control policies.

On 7/30/14 at 2:10 PM, the surveyor performed an observation of wound care with EI # 18, LPN. A glove and gown precaution notice was posted on the patient door. EI # 18 donned gown and gloves and entered the room. EI # 18 did not perform hand hygiene before gloving.

EI # 18 removed the old dressing and discarded the dressing and gloves in a red biohazard bag. EI # 18 donned clean gloves, but failed to perform hand hygiene after glove removal.

EI # 18 cleansed the wound with betadine and gauze 3 times and removed gloves and discarded. EI # 18 obtained additional gloves from the glove box in the patient room. EI # 18 did not perform hand hygiene after removing gloves and contaminated the box of gloves in the patient room.

EI # 18 cleansed the wound site with gauze and sterile water and applied a dressing. EI # 18 removed gloves and discarded the gauze and gloves to the biohazard bag. EI # 18 exited the room, removed the gown and placed the gown in the biohazard bag in the soiled utility room. EI # 18 then used hand sanitizer.

In an interview at 2:25 PM on 7/30/14, EI # 18 verified hand hygiene was not performed as per facility policy. EI # 18 failed to follow facility policy for Contact Precaution use.




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Policy and Procedures:
Guidelines for Isolation Precautions # 2011

" Modes of Transmission
There are 3 primary routes by which patients are exposed to microorganisms in healthcare settings:

Contact transmission:
Direct: Microorganisms are transferred directly from person to person...

Indirect: The most frequent mode of transmission; pathogens are transferred through a contaminated intermediate object or person.

Hands of HCW (Health Care Worker) touch an infected or colonized patient site or a contaminated inanimate object and subsequently touch another patient without performing hand hygiene between patient contacts.

Unwashed hands are the most frequent cause of pathogen transfer resulting in Healthcare Associated Infections (HAIs).

Patient care devices (i.e. electronic thermometers, glucose monitoring devices) contaminated with a patient's blood or body fluids are shared among patients without cleaning and disinfecting between patient contacts...

Personal Protective Equipment (PPE):
Assuming that all patients are potentially infected or colonized, HCWs must create barriers and use respirators to protect mucous membranes, skin and clothing from contact with these infectious agents. The type of protection will depend upon the tasks involved and the proximity of the patient. The following sections list the type of barrier and the rationale for its use:

Gloves: Gloves should be donned whenever there is a possibility of contact with the patient's blood or body fluids, mucous membranes or non-intact skin... It is often necessary to change gloves while caring for a patient to prevent cross-contamination from one patient site to another. Whenever gloves are changed, hand hygiene should be practiced before donning a clean pair of gloves... Gloves should not be worn outside the patient room and should be removed and disposed of before removing other PPE.

Isolation Gowns: Gowns should be worn to protect the HCWs clothing from being contaminated with a patient's blood or body fluids and/or other transmittable infectious agents... Gowns should be removed in the patient's room... It should be discarded into a designated container.

Standard Precautions:
PPE's are used to prevent HCWs from contact with infectious agents and then carrying them from patient to patient...

Expanded Precautions:
Expanded precautions consist of four categories: Contact Precautions, Droplet Precautions, Airborne Infection Isolation (All) and Protective Environment. These precautions are in addition to Standard Precautions.

Contact Precautions:
These precautions are to be used to reduce the risk of transmission of resistant microorganisms by direct or indirect contact with a patient and/or patient's environment...
All PPE's should be removed and discarded appropriately in the patient's room before exiting... Hand hygiene should always be done before leaving the room either with soap and water or alcohol-based hand rub...
HCWs should always explain the necessity of PPE's and expanded precautions to the patient and patient's family. "

Observations:

MR # 14 was admitted to the facility 7/29/14 with diagnoses of Cellulitis/ Abscess Arm and Diabetes Mellitus Type II, Hypertension and Renal Insufficiency.

The patient was placed on Contact Isolation on admission by nursing staff due to the draining abscess.

On 7/30/14 at 6:21 AM the nurse documented, " Pt bandage removed. Softball size abscess under righ axillary. Large amount of purulent drainage noted. Redness and swelling also noted. Nurse from OR (operating room) came to transport pt to surgery."

On arrival to the facility 7/30/14 at 7:05 AM the surveyor observed MR # 14's room door standing open with the isolation bag hanging over the outside of the door. The bed was unoccupied and a female was sitting in the chair at the bedside.

The patient was taken to surgery 7/30/14 for incision and drainage of the abscess of the right axilla. Cultures were obtained, the wound was irrigated with saline and packed with iodorform gauze. The documented plan was to remove packing tomorrow and re-irrigate.

A second observation of the room at 7:30 AM revealed the door was closed.


A medication pass observation was performed with MR # 14 on 7/30/14 at 8:30 AM with EI # 12, LPN. There was a sign on the door for use of Contact Precautions, gown and gloves required. EI # 12 donned gown and gloves and entered the patient ' s room with the chart cart and glucometer. EI # 12 failed to perform hand hygiene before donning gloves.

EI # 12 administered 4 po (oral) medications and performed a blood glucose test. EI # 12 exited the room, removed gown and gloves and placed them in a red biohazard bag. EI # 12 cleansed his/her hands with hand sanitizer, then pushed the chart cart down the hall to the soiled utility room. EI # 12 discarded the red bag in the soiled utility room. EI # 12 asked a housekeeping employee to wipe the glucometer with Clorox Cleanup wipe. EI # 12 removed the gloves and gown after leaving the patients room, failed to perform hand hygiene after disposal of the biohazard bag. The chart cart was not disinfected after leaving the room with Contact Precautions in use.

During an interview on 7/31/14 at 10:30 AM with EI # 1, RN (Registered Nurse), Nurse Manager confirmed staff failed to follow facility infection control policies.


On 7/30/14 at 11:00 AM two small boys were observed running in the hallway, when asked where they were going they ran into MR # 14's room and left the door standing open, the boys did not observe the rules for isolation.

Approximately 10 minutes later the boys exited the room leaving the door standing open and MR # 14 was observed sleeping in the bed with siderails up.

The nurses failed to educate the patient and family members of the need for isolation. The nurse failed to ensure isolation policies were followed for the safety of the patient and the public.

In an interview 7/31/14 at 10:50 AM with EI # 1, she stated she did not know what to say regarding the observations.





28327

During a tour of the Post Anesthesia Care Unit (PACU) on 7/30/14 at 7:24 AM the surveyor observed EI # 3, Operation Room (OR) Manager, typing at the computer terminal. EI # 3 proceeded to bed 2, applied gloves and removed the Intravenous (IV) tubing line from MR # 14. EI # 3 then removed the gloves and returned to the computer terminal and began typing. EI # 3 did not perform hand hygiene before applying or after removing gloves.

At 7:40 AM EI # 3 then applied gloves, returned to MR # 14's bedside and proceeded to remove a dirty saturated chux from underneath MR # 14. EI # 3 requested another staff member to bring him/her a red bag to place the chux in. While waiting for the red bag and holding the saturated chux, EI # 3, proceeded to retrieve MR # 14's chart and place it on the stretcher. After placing the dirty saturated chux in the red bag, EI # 3, then removed his/her gloves and prepared MR # 14 for transport to the floor without performing hand hygiene.

In an interview 7/30/14 at 11:40 AM, the above findings were confirmed by EI # 3, OR Manager. EI # 3 confirmed MR # 14 had an Incision and Drainage (I & D) procedure and hand hygiene with blood and body fluids precautions should be carried out.

Based on observation, review of the Infection Control Committee Minutes, and interview, it was determined the facility leadership failed to address problems identified by the infection control committee and take corrective action. This affected Medical Record (MR) # 13 and has the potential to affect all newborns delivered at this facility.

Findings Include:

On 7/29/14 at 1:19 PM the surveyor observed the delivery of MR # 13.

At 3:11 PM, the surveyor observed MR # 13 lying in the isolette in the entrance to the nurses' station on the postpartum and medical/surgical unit which also provided care to patients requiring isolation. The surveyor asked EI # 13, the Unit Secretary, why the baby was at the nurses' station. EI # 13 stated, "I am waiting on the nurse to return from lunch and I am watching the baby until then". The surveyor asked, "Does that happen often?" EI # 13 replied, "Yes all the time".

From 3:19 PM to 3:29 PM the surveyor observed multiple staff touching and moving MR # 13's isolette from the nurse's station entrance to the connecting supply room entrance.

A review on 7/31/14 at 11:00 AM of the 12/19/2012 Infection Control Meeting Minutes read as follows:
Topic
V. New Business
...Newborns
Findings: Kept at nurses' station when not rooming in with mother and is an infection control / security issue.
Recommendations: Discuss options for nursery nurse; revise policies.

A review on 7/31/14 at 11:00 AM of the 10/30/2013 Infection Control Meeting Minutes read as follows:
Topic
III. New Business
... Babies at nurses' station
Findings: Caring for babies at the nurses' station is an infection control issue.
Recommendation: Ensure that nurses taking care of isolations pt's (patients) use proper isolation precautions to prevent cross contamination if handling baby. Do not change or feed baby at the nurses' station. Take baby to mother's room.

The facility failed to address the issue of babies being taking care of at the nurses' station as identified in 2012 and 2013.

In an interview on 7/31/14 at 11:20 AM with EI # 5, Infection Control (IC) Nurse, confirmed the aforementioned findings. EI # 5, stated, "I didn't feel comfortable with babies at the nurses' station so I took it to the IC Committee and administration".

Based on observation and interview with staff, it was determined the facility failed to ensure all anesthesia carts were secured and locked in the facility. This had the potential to negatively affect all patients receiving care in this facility.

Findings Include:

1. A tour of the Obstetrical Unit was conducted by the surveyor 7/29/14 at 10:25 AM with Employee Identifier (EI) # 21, the Director of Nursing. The surveyor observed an Anesthesia Cart labeled, "Epidural Cart" in the unsecured/unlocked hallway of the Labor & (and) Delivery Unit. There was no lock on the Epidural Cart.

Additional observations were conducted on 7/30/14 at 10:15 AM and 7/31/14 at 7:05 AM of the L & D department to observe the Anesthesia Cart. There was no lock on the Epidural Cart.

2. An observation was conducted in the Surgery department on 7/30/14 at 7:24 AM with EI # 3, the Operation Room (OR) Manager. The surveyor observed there was no lock on the OR # 1 Anesthesia Cart.

On 7/30/14 at 12:25 PM the surveyor requested the facility policy regarding the locking of the anesthesia carts. EI # 3, OR Manager and EI # 27, Certified Registered Nurse Anesthetist (CRNA), confirmed the facility did not have a policy and stated, "We will have to make one".

In an interview 7/31/14 at 11:30 AM, EI # 7, Administrator, confirmed the Anesthesia Carts should be locked.

Based on record review, Rules of Alabama State Board of Health Chapter 420-4-4 Rabies Control Program and interviews, it was determined the facility failed to follow the law requiring dog bites be reported to the proper authorities for 1 of 3 emergency room patients admitted with dog bites. This affected emergency room records (ER) # 9 and had the potential to affect all patients who presented to the ED with animal bites.

The ER staff failed to ensure ER records in 4 of 30 ER records reviewed were completed related to:

1. The disposition and condition of the patient at discharge.

2. Vital signs were recorded prior to discharge.

This had the potential to affect all patients served by the emergency department.


Findings include:

Rules of Alabama State Board of Health Chapter 420-4-4
Rabies Control Program

420-4-4.03 Reporting of Exposures. Suspected exposures to humans by animals capable of transmitting the rabies virus shall be reported to the county health department.

" (a) Who shall report. The following individuals shall report exposures:

1. Health care professionals who treat persons with suspected exposures.

(b) What shall be reported. Suspected exposures by an animal to a human shall be reported to the county health department.

(c) When and how to report. Suspected exposures must be reported to the county health department within 48 hours of the exposure. Reports may be given by written notice, telephone or any reliable telecommunication system (facsimile; email)."

Medical Record Findings:

1. ER # 9 was admitted to the ED on 6/2/14 with a chief complaint of a dog bite to the left forearm.

Review of the ED record revealed the physician place 5 stitches to the forearm.

There was no documentation the incident was reported to the county health department in the ER record provided to the surveyor.

In an interview with Employee Indentifer (EI) # 6, the ER Nurse Manager on 7/31/14 at 12:05 PM, the above information was confirmed.

2. ER # 1 was admitted to the ED on 5/28/14 with a chief complaint of suicidal thoughts.

The Emergency Physician's Record failed to have a date and time seen, the first section of the form was not completed by the physician.

The disposition time and condition was not completed by the ER physician.

In an interview with EI # 6, the ER Nurse Manager on 7/31/14 at 12:05, the information was confirmed.

3. ER # 26 was admitted to the ED on 6/27/14 with a chief complaint of Accidental Drug Overdose brought in by girlfriend in a private vehicle.

The patient was transferred to another facility after being stabilized. The ER record provided to the surveyor failed to have a consent for transfer form signed in the record.

In response to written questions presented to EI # 7, the Administrator 7/30/14 at 4:00 PM, the surveyor received faxed copies of the Air Evac Medical Necessity forms received by the hospital 7/30/14 at 5:14 PM. EI # 7 presented the forms with written answers to the questions from the ER staff to the surveyor at 8:30 AM on 7/31/14.

The Air Evac forms were signed by the ER physician 6/27/14.

4. ER # 29 was admitted to the ED 7/1/14 with a complaint of bring assaulted by her ex-boyfriend.

The Emergency Physician's Record failed to have a disposition time on the form.

The nurse failed to record vital signs (VS) at the time of discharge.

In response to written questions presented to EI # 7, the Administrator on 7/30/14 at 4:00 PM, the surveyor received written confirmation, " Findings noted- disposition times addressed with this physician just last week, VS on discharge are protocol."