HospitalInspections.org

Based on observations, review of the Patient Information Booklet given to all patients and interviews with facility staff, it was determined the facility failed to provide the patients or the patient's representative a phone number and address for lodging a complaint or grievance with the State Agency. This had the potential to affect all patients.

Findings include:

1. During a tour of the Emergency Department (ED) on 10/19/10 at 11:15 AM, it was noted that the hospital did not have posted the toll free State hot line phone number for patients to call to voice grievances.

An interview with Employee Identifier (EI) #1, the Chief Nursing Officer, on 10/19/10 at 11:15 AM confirmed the toll free State hot line phone number was not posted.

2. On 10/19/10 at 11:25 AM a review of the Patient Information Booklet revealed the State Agency hot line number to file grievances and complaints was not listed.

On 10/19/10 at 11:25 AM, EI #1 stated the Patient Information Booklet was provided to all patients including Emergency Department patients and outpatients. EI #1 confirmed the State Agency hot line number was not listed in the Patient Information Booklet.

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

Findings include:

Refer to Life Safety Code violations.

Based on record review, interview with facility staff and review of the Alabama State Board of Health Chapter 420-4-4, it was determined the hospital failed to follow the reporting requirements to the Alabama State Board of Health in 3 of 5 Emergency Department (ED) records reviewed with animal bites. This affected ED records # 6, 15 and 18.

Findings include:

Alabama State Board of Health

Alabama Department of Public Health

Division of Disease Control Administrative Code

Chapter 420-4-4 Rabies Control Program

420-4-4-.04 Reporting Exposures

(1) Who Must Report. Any health care professional who treats an animal bite or exposure, any veterinarian who has knowledge of an animal bite or exposure, and any law enforcement personnel, including animal control officials, who have been informed of or investigated an animal bite or exposure must report the incident.


1. ED record # 6 was admitted on 7/3/10 with a dog bite to the left forearm. A review of the medical record revealed no documentation of this incident being reported to the state health department.

An interview with Employee Identifier (EI) #6, the Assistant Chief Nursing Officer, on 10/21/2010 at 10:19 AM revealed there was no documentation of the dog bite being reported.

2. ED record # 15 was admitted on 7/11/10 with a dog bite to the left wrist. A review of the medical record revealed no documentation of this incident being reported to the state health department.

An interview with EI #6 on 10/21/2010 at 10:19 AM revealed there was no documentation of the dog bite being reported.

3. ED record # 18 was admitted on 8/1/10 with a dog bite to left lower leg. A review of the medical record revealed no documentation of this incident being reported to the state health department.

An interview with EI #6 on 10/20/2010 at 2:25 PM revealed there was no documentation of the dog bite being reported.

Based on medical record review, review of policy and procedures and interviews, it was determined the facility failed to ensure a physician's order was obtained for wound care. This affected 2 of 2 wound care medical records (MR # 4 and 5) reviewed for wounds.

The findings include:

Policy and Procedure #616
"Assessment/ Reassessment of the wound care Patient"
Effective 1/01/10

"Procedure: ... B. All Therapy assessment/ evaluations request require a physician's order prior to assessment. Results of the initial evaluation/plan of care will be sent to the referring physician to be returned with a signature in a timely manner per department policy. For inpatient acute medical-surgical patients the plan of care will be entered into the medical record by the end of the day on the date of the evaluation for review by the referring physician."

Medical Record (MR) # 4 was admitted to the facility on 8/19/10 with a diagnosis of Peri-rectal Abscess. MR# 4 had surgery on 8/19/10 and was sent to Physical Therapy (PT). On 8/20/10 the Initial PT Evaluation documented, "... irrigated mult (multiple) times with NS (normal saline) ... saline damp Nugauze and covered with 1/4 ABD (abdominal) pad." There was no physician order for this specific dressing change.

MR# 5 was admitted to the facility on 8/18/10 with a diagnosis of Right Thumb Infection. A PT note dated 8/21/10 revealed, " Bacitracin to puncture. Covered incision with Xeroform, 4X4, 2" (inch) Kling." There was no physician order for this specific dressing change.

During an interview on 10/20/10 at 8:10 AM, with Employee Identifier (EI) # 9, the Physical Therapy Director, she verified there was no documentation of physician orders for the specific wound cleaning and dressings to be done for MR #4 and # 5.

During an interview on 10/20/10 at 3 PM, with EI# 6, the Assistant Chief Nursing Officer, he verified there was no documentation of physician orders for the specific wound cleaning and dressings to be done for MR #4 and # 5.