HospitalInspections.org

Based on review of medical records, policy and procedures,Alabama Board of Nursing Standards of Practice and interview it was determined the nursing staff failed to:

1. Document wound assessments to include appearance of the wound/ wound bed and surrounding tissue, exudates, drainage, odor, signs and symptoms of infection, measurements, and consistent site labeling and stages of wounds

2. Document specific wound care provided

3. Have orders for wound care provided.

This affected 3 of 5 medical records reviewed of patients with wounds (Medical Record (MR) #s 8, 5 and 10) and had the potential to negatively affect all patients with wounds served by this facility.

Findings include:

Alabama Board of Nursing Chapter 610-X-6
Standards of Nursing Practice

610-x-6-.13 Standards for Wound Assessment and Care

(1) It is within the scope of a registered nurse or licensed practical nurse practice to perform wound assessments including, but not limited to, staging of a wound and making determinations as to whether wounds are present on admission to a healthcare facility pursuant to an approved standardized procedure...

(2) The minimum training for the registered nurse or licensed practical nurse that performs selected tasks associated with wound assessment and care shall include:
(a) Anatomy, physiology and pathophysiology.
(c) Equipment and procedures used in wound assessment and care.
(d) Chronic wound differentiation.
(e) Risk identification.
(f) Measurement of wound.
(g) Stage of wound.
(h) Condition of the wound bed including:
(i) Tissues
(ii) Exudates
(iii) Edges
(iv) Infection
(i) Skin surrounding the wound...

610-X-6-.06 Documentation Standards

(1) The standards of documentation of nursing care provided to patients by registered nurses or licensed practical nurses are based on principles of documentation regardless of the documentation format.

(2) Documentation of nursing care shall be:
(a) Legible
(b) Accurate
(c) Complete. Complete documentation includes reporting and documenting on appropriate records a patient's status, including signs and symptoms, response, treatments, medications, other nursing care rendered, communication of pertinent information to other health team members, and unusual occurrences involving the patient...

Policy: Wound Vacuum Application
Effective: January 2014

Policy:
It is the policy of Clay County Hospital to utilize wound vacuums for the treatment/healing of wounds when ordered by the physician.

Wound V.A.C. ( Vacuum Assisted Closure) Dressing Change
Wash hands
Apply non-sterile gloves...
Remove old dressing...
Cleanse wound bed with normal saline or wound cleanser to remove debris...
Examine wound bed. It should have pink/red granulation tissue. Note any drainage, tunneling, cavities.
Assess wound size. Measure wound.
Check condition of periwound skin...
Document dressing change in chart.

Policy: Decubitus: Decubitus Protocol Prevention and Care
Revised Date: August 2012

Policy:
It is the policy of Clay County Healthcare Authority that all patients admitted to Clay County Hospital shall receive a complete head-to-toe assessment, at which time a thorough examination of the skin will be done, If the patient has a decubitus ulcer(s) or if one develops during stay at this facility for medication treatment, a photograph may be taken.

At the first sign of pressure sore/decubitus medical treatment:
1. A "Consent to photograph" form must be completed.
2. An initial photograph shall be taken of each decubitus stage and as needed...
4. Measure decubitus and document size.
6. Call physician to report and for treatment orders.
7. Record the date and time of initial and subsequent treatment, per physician's orders.

Documentation:
1. Record the date and time of initial and subsequent treatment.
2. Document the area(s) on the diagrams of the locations of the pressure sores on the wound assessment section of the flow chart.
3. Document the size (length and width), the depth and the exudate (amount, color, and odor).
4. Note any change in the condition or size of the ulcer and any elevation of skin temperature in the Nurses Notes...

1. MR # 8 was admitted to the hospital 4/8/14, from a skilled nursing facility, with a wound VAC (negative pressure wound therapy). Admitting diagnosis was Cellulitis of back, legs and buttocks.

Review of the Nursing Patient Progress notes revealed the following entry by the LPN (Licensed Practical Nurse) at 6:10 AM on 4/9/14. "Dr. H... in on AM rounds. Wound vac off and dressing dc'd (discontinued) per MD (doctor) to visualize wound. New orders received..." On 4/9/14 the physician wrote an order to "clean decubitus with Hibiclens. Use Dakin's solution wet to dry dressing until new wound VAC supplies available." There was no documentation the nurse performed the Dakins solution wet to dry dressing. Review of the medical record revealed no documentation orders were written for application of the wound VAC.

Review of the Unisex Body Sheet dated 4/9/14 at 7:19 AM revealed the wound was documented as Site "A" Stage 3.

Further review of the nurse's notes revealed an entry by the LPN dated 4/9/14 at 7:40 PM documented, "...Wound Vac intact to decub. (decubitus) on sacral area. There was no documentation of the application of the wound V.A.C.

Review of the nurse's note dated 4/11/14 6:32 AM revealed the following documentation: "...MD noted an open area on left buttock, ordered a polymem 4x2 covering placed over open area...another open area was noted to the right buttock; this area was covered with a 2x2 polymem..." There was no documentation of an order related to wound care to these two new areas and no wound measurements.

Review of nurse's note dated 4/12/14 7:25 AM, amended 10:09 AM, revealed documentation the wound on coccyx was now "Stage IV" and in the Description of wound section, it was documented as "Stage 5." Further review of the nurse's note dated 4/12/14 @ 7:37 PM, revealed the coccyx wound was documented as a "Stage III." There was no consistent documentation of the wound stage.

Review of the nurse's note dated 4/13/14 6:15 AM revealed the following documentation,"...reapplied polymem 4x4 to right and left buttock..." There was no documentation of an order to provide this wound care, and no description of wounds, including measurements, was documented by the nurse.

Review of nurse's note dated 4/14/14 3:15 PM revealed the following documentation: Dressing: "Wound cleansed and wound vac dressing applied as per protocol..." There was no documentation of what the wound was cleansed with and what type dressing was applied.

Review of the Unisex Body Diagrams between 4/8/14 to 4/15/14 revealed inconsistent documentation of the location of the wounds as follows:

Site A(A) - Site B (B) - Site C (C)

4/8/14 - 4/10/14 - A = Coccyx (Only documented wound at this time)

4/11/14 at 6:32 AM - A = Left Buttock, B = Right Buttock, C = no documentation of a wound

4/11/14 at 7:25 AM - A = Coccyx, B = Left Buttock, C = Right Buttock

4/11/14 at 8:06 PM - A = Left Buttock, B = Sacrum, C = Right Buttock

4/12/14 at 7:25 AM - A = Coccyx, B = Left Buttock, C = Right Buttock

4/12/14 at 7:37 PM - A = Left Buttock, B = Sacrum, C = Right Buttock

4/13/14 at 8:31 AM - A = Coccyx, B = Right Buttock, C = Left Buttock

4/13/14 at 7:19 PM - A = Left Buttock, B = Sacrum, C = Right Buttock

4/14/14 at 7:57 AM - A = Left Buttock, B = Right Buttock, C = Coccyx

4/14/14 at 8:02 PM - A = Left Buttock, B = Sacrum, C = Right Buttock

4/15/14 at 8:05 AM A = Sacral

An interview was conducted on 7/10/14 at 1:25 PM with Employee Identifier (EI) # 5, Chief Nursing Officer (CNO), who confirmed the above mentioned findings.

2. MR # 5 was admitted to the hospital from a skilled nursing facility on 1/3/14 with a primary diagnosis of MRSA (Methicillin Resistant Staphylococcus aureus) sepsis and multiple organ failure.

Review of the MR revealed a physician verbal order dated 1/4/14 3:05 PM that reads: "Change wound VAC foam dressing at 125 mmHg (millimeters of mercury) negative pressure on left hip on Mondays, Thursdays, and PRN (as needed). Apply Santyl to wound bed and skin prep to surrounding wound tissue. Seal with transparent dressing." There was no documentation in the physician's orders of the product to use to clean the wound.

Further review of the MR revealed a Unisex Body diagram dated 1/3/14 9:35 PM noting Site A as left hip and Site B as Left leg posteriorly. Site B was noted to be a "stage 2, split, 1 inch x approximately 1/4 inch opening." There was no documentation of wound care orders for Site B. Review of the nurse's note 1/4/14 at 8:30 PM documented "Dressing: Dry and intact."

Review of the MR revealed a physician's order dated 1/5/14 at 8:00 PM: "Butts Paste (Boudreaux's) to affected areas prn (as needed). There was no documentation on the physician's order of the location of the "affected areas", or what to use to clean the "affected areas".

Review of the nurse's note dated 1/5/14 (Sunday) 16:12 revealed documentation of wound interventions: "Wound VAC dressing changed to left hip. Santyl applied. Packed with Granufoam as previous dressing. Secured with Tegaderm dressing...Positive VAC seal achieved..." There is no documentation of wound measurements, what wound was cleaned with, or amount of negative pressure applied to the wound per the VAC.

Review of the nurse's notes reveal no documentation the wound VAC dressing was changed as ordered on Monday 1/6/14, and Thursday 1/9/14.

Review of the Unisex Body diagrams revealed inconsistent documentation of wound locations:

Date - Site A (A) - Site B (B) - Site C (C) - Site D (D)

1/3/14 - Left hip - A = Left leg posteriorly

1/6/14 - A = Left calf, B = Right knee, C = Left heel, D = Left hip

1/7/14 - A = Left calf, (B) = Right knee, C = Left heel, D = Left hip

1/9/14 - A = Left hip and B = LLE (left lower extremity)

An interview was conducted with EI # 5, CNO on 7/10/14 at 1:20 PM, who verified the above mentioned findings.



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3. MR # 10 was admitted to the facility on 5/29/14 with an admitting diagnosis of Pseudomonas of open wound to sacrum. Patient was admitted at this time as Swing Bed status.

Review of the Medical Record (MR) revealed the Initial Nursing Assessment dated 5/29/14, the nurse documentated the patient had a stage 3 decubitus ulcer to the sacral area.

Further review revealed the initial physician order was to apply a wound vacuum to sacral area with continuous suction at 100 mmHg (millimeters of mercury) /min (minute) and to change every Monday and Thursday.

Review of the nurses notes from 5/29/14 to 6/30/14 revealed the only documentation of wound measurements were on the Initial Nursing Assessment dated 5/29/14 and the nurse's noted dated 6/20/14.

Review of the Unisex Body documentation revealed there were no wound measurements completed at time of dressing change on Mondays or Thursdays.

Further review of the patient's MR revealed no documentation of a consent for photography was signed and no documentation of a photograph of the patient's wound was entered into the chart per facility policy.

Review of the nurses notes dated 5/30/14 to 6/30/14 revealed incomplete documentation of when the dressing change occurred, what type and number of foam pieces were removed and were used to complete dressing change.

Review of the nurses note dated 6/12/14 revealed the nurses documentated he/she cleaned the wound with Wound Care Solution.

Review of the Physician's Orders revealed there was no order written to clean the wound.

An interview conducted on 7/9/14 at 8:00 AM with EI #6, ADON (Assistant Director of Nursing) confirmed the above mentioned findings.

Based on review of Medical Records (MR), facility's policy, and interviews with the staff it was determined the facility failed to ensure that all physician's orders were written and entered into the patients MR. This affected MR #s 10, 8, and 5 (3 of 5 medical records reviewed with wounds) and had the potential to affect all patients served by this facility.

Findings include

Policy: Physician Orders
Revised Date: September 2012

Policy:
It is the policy of Clay County Healthcare Authority to provide a safe and uniform method of receiving and transcribing physician's orders.

A. Transcription Order:
2. Routine orders shall be transcribed as soon as possible.
7. New medication orders shall be transcribed to the medication sheet in a timely manner of physician writing the order.

B. Verification of Physician Orders:
The purpose is to verify the follow-through and transcription of physicians' orders from the previous shift. To ensure patient safety and comply with the standards of care. To verify the necessity to initiate, continue, continue or change appropriate treatments and preparations as ordered. To maintain appropriate continuity in patient care.

1. Every RN (Registered Nurse) and LVN (Licensed Vocational Nurse) /LPN (Licensed Practical Nurse) will be responsible to ensure that the physician's orders for each patient has been carried out as ordered.

1. MR # 10 was admitted to the facility on 5/29/14 with an admitting diagnosis of Pseudomonas of open wound to sacrum. Patient was admitted at this time as Swing Bed status.

Review of the nurses note dated 6/12/14 revealed the nurse documentated he/she cleaned the sacral wound with Wound Care Solution.

Review of the Physician's Orders revealed no documentation of a order to clean the wound.

An interview conducted on 7/9/14 at 8:30 AM with Employee Identifier (EI) # 6, Assistant Director of Nursing verified the above mentioned findings and stated it was part of their policy for the wound Vacuum and was not aware a physician's order needed to be written.



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2. MR # 8 was admitted to the hospital 4/8/14, from a skilled nursing facility, with a wound VAC (Vacuum Assisted Closure) intact to the coccyx. Admitting diagnosis was Cellulitis of back, legs and buttocks.

Review of the Nursing Patient Progress notes revealed the following entry by the LPN (Licensed Practical Nurse) at 6:10 AM on 4/9/14. "Dr. H... in on AM rounds. Wound vac off and dressing dc'd (discontinued) per MD (doctor) to visualize wound. New orders received..." On 4/9/14 the doctor wrote an order to "clean decubitus with Hibiclens. Use Dakin's solution wet to dry dressing until new wound VAC supplies available." No orders were written for application of the wound VAC.

Review of the nurse's notes revealed an entry by the LPN dated 4/9/14 at 7:40 PM documented, "...Wound Vac intact to decub. (decubitus) on sacral area..." There is no order from the physician for the application of the wound VAC.

Review of the nurse's note dated 4/11/14 6:32 AM revealed the following documentation: "...MD noted an open area on left buttock, ordered a polymem 4x2 covering placed over open area...another open area was noted to the right buttock; this area was covered with a 2x2 polymem..."
There was no documentation of an order for wound care to these two new wounds.

An interview was conducted on 7/10/14 at 1:25 PM with EI # 5, Chief Nursing Officer (CNO), who confirmed the above mentioned findings.

3. MR # 5 was admitted to the hospital from a skilled nursing facility on 1/3/14, with a wound VAC intact to the left hip. The primary diagnosis on admission was MRSA (Methicillin Resistant Staphylococcus aureus) sepsis and multiple organ failure.

Review of the MR revealed a physician verbal order dated 1/4/14 3:05 PM stated: "Change wound VAC foam dressing at 125 mmHg (millimeters of mercury) negative pressure on left hip on Mondays, Thursdays, and PRN (as needed). Apply Santyl to wound bed and skin prep to surrounding wound tissue. Seal with transparent dressing." There was no documentation on the physician's verbal orders of what product to use to clean the wound.

Review of the MR revealed a Unisex Body diagram dated 1/3/14 9:35 PM noting Site A as left hip and Site B as Left leg posteriorly. Site B was noted to be a "stage 2, split, 1 inch x approximately 1/4 inch opening." There was no documentation of a physician's order for wound care to site B (left leg).

Review of the nurse's note dated 1/4/14 at 8:30 PM, revealed a Wound Assessment which documented "Dressing: Dry and intact."

Review a physician's order dated 1/5/14 at 8:00 PM revealed, "Butts Paste (Boudreaux's) to affected areas prn (as needed). The order was incomplete and did not include the location of the "affected areas" or what produce to use to clean the "affected areas".

An interview was conducted with EI # 5 on 7/10/14 at 1:20 PM, who confirmed the above mentioned findings.

Based on observation, review of CDC (Centers for Disease Control) safe practices for use of multi-dose vials, facility policy and procedures and interview with staff, it was determined the facility failed to ensure:

1. All medications and biologicals available for patients were not expired.

2. All multi-dose vials were labeled with the date opened.

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

Findings include:

CDC- Multi-dose vials- Safe Practices last updated 2/9/11

Questions about multi-dose vials:

4. When should multi-dose vials be discarded?

Medication vials should always be discarded whenever sterility is compromised or questionable.

In addition, the United States Pharmacopeia (USP) General Chapter 797 recommends the following for multi-dose vials of sterile pharmaceuticals:

If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

If a multi-dose vial has not been opened or accessed (e.g., needle-punctured), it should be discarded according to the manufacturer's expiration date.

The manufacturer's expiration date refers to the date after which an unopened multi-dose vial should not be used. The beyond-use-date refers to the date after which an opened multi-dose vial should not be used...
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Policy: Removal and Destruction of Medications
Revised: 7/9/10

Purpose:
To remove and properly dispose of out of date medications from the pharmacy, and other areas of the Hospital where medications are stored...

Policy:
Each month Pharmacy will remove medications expiring by the end of the month from the Pharmacy, Omnicell machines and any other areas of the hospital and nursing home that store medications.

Expired medications will be held in the pharmacy until the reverse distributor removes them...

An observation was conducted in the Pharmacy Department on 7/8/14 at 1:30 PM. The surveyor observed the following expired medications:

1 - NaCl (sodium chloride) 0.9% flush 10 ml (milliliters) single dose vial expired 3/14

5 - Nafcillin 2 gram/ADD-Vantage Vials expired 5/14

An interview was conducted on 7/8/14 at 2:15 PM with EI (Employee Identifier) # 7, Pharmacy Technician, who verified the dates of the expired medications.

A single Fenofibrate 48 mg (milligram) tablet was found in a baggie labeled with the patient name and a date of 10/23/13. There was no documentation of an expiration date. An interview conducted on 7/8/14 at 2:30 PM with EI # 4, Pharmacy Director, stated this had been sent to a patient on the floor and returned to the pharmacy.

A multi-dose vial Humulin R insulin had an expiration date of 7/23/14.

The above findings were verified with EI # 4 on 7/8/14 2:45 PM.

A tour of the Radiology Department was conducted on 7/8/14 at 12:45 PM with EI # 9, Assistant Radiology Director revealed the Pressure Injector used for injecting intravenous contrast had not had a Performance Maintance since 9/6/12.

A tour of the Nuclear Medicine Department was conducted on 7/8/14 at 1:30 PM with EI # 10, Nuclear Medicine Technician, revealed a Nitroglycerin Spray 400 mcg (micrograms) pinned to the wall in the stress lab with an expiration date of 9/13.

Based on United States Health Public Food Code 2009 regulations, observations and interview, it was determined the hospital failed to ensure food was stored in a safe and sanitary manner.

This had the potential to negatively affect all patients.

Findings include:

United States Health Public Food Code 2009

3-501.17 Ready-to-Eat, Potentially Hazardous Food
(Time/Temperature Control for Safety Food),
Date Marking.
...commercially processed food open and hold cold
(B) Except as specified in (D) - (F) of this section, refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety...

(C) A refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) ingredient or a portion of a refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is subsequently combined with additional ingredients or portions of food shall retain the date marking of the earliest- prepared or first prepared ingredient.

(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include:...
(2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section;
(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section...


During a tour of the Dietary Department on 7/8/14 at 3:30 PM with Employee Identifier (EI) # 2, Dietary Manager the surveyor observed opened food containers with no dates, food items which had expired and inappropriately stored food items.

Located in the dry storage area were the following inappropriately stored food items which were expired:

3 - 16 ounce (oz) containers of Chocolate sauce expired 4/14.
1 - 16 oz container of Butterscotch sauce labeled with an open date of 5/14/13.
2 - Lemon Bar Filling mix 46 oz boxes expired as of 6/17/14 and 3/14/14.

The following items were opened with no date:

2 - 14 oz bags of country gravy mix

Gallon size containers of Soy Sauce, Kitchen Banquet (smoke flavor), Vinegar, Sesame Oil, Pancake Syrup, and Teriyaki Sauce.

24 oz bag of Drink mix.
2 - 16 oz bags of Cheese Sauce.
2 - 24 oz bags of Instant Potatoes.
36 oz bag of Cornbread Stuffing mix.

An interview was conducted on 7/9/14 at 10:00 AM with EI # 2, who confirmed the items listed above were expired, inappropriately stored and were opened and not dated.

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 by the hospital.

Findings include:

Refer to Life Safety Code violations for findings.

Based on observations and interviews with facility staff it was determined the facility failed to:

A. Ensure equipment was monitored to maintain safety of patients and staff.

B. Ensure all medical supplies available for patient use in the Radiology, Nuclear Medicine, Emergency and Outpatient Departments stored properly and were not expired.

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

Findings include:

Facility Policy:
Subject: Environmental Services Safety
Revised date: 11/2013

Policy:
Clay County Healthcare Authority employees shall maintain a safe work environment.

Procedure:

6. Cleaning agents shall not be left unattended in areas where patients or other persons might come in contact with them.

A tour of the Emergency Department was conducted on 7/8/14 at 10:45 AM with Employee Indentifer (EI) #8, Emergency Department (ED) Manager, and the surveyor observed the following: Exam Room #3 had a plastic spray bottle labeled with Cavicide # 3, Exam Room # 4 had 3 cans of aerosol cleaners on the top shelf and on the bottom shelf a plastic spray bottle labeled with Cavide # 4. During the tour EI # 8 stated the above items were used to clean the rooms.

A tour of the Radiology Department was conducted on 7/8/14 at 12:45 PM with EI # 9, Assistant Radiology Director revealed the Pressure Injector used for injecting intravenous contrast had not had a Performance Maintance since 9/6/12.

A tour of the Outpatient Department was conducted on 7/9/14 at 2:15 PM with EI # 10, Registered Nurse. The surveyor observed in room # 219 the following expired lab tubes:

8 - green top tubes expired 10/13.
15 - red top tubes expired 6/14.
11 - blue top tubes expired 11/13.

The surveyor observed a blue bowl under the sink containing numerous instruments such as scissors, tweezers and hemostats. There was a dried residue in the bottom of the bowl. The staff were unsure how long these instruments had been under the sink.


An interview was conducted on 7/9/14 3:30 PM with with EI # 12, Director of Outpatient Department and the above mentioned findings were verified.

Based on The Centers for Disease Control (CDC) Guidelines for Hand Hygiene in Health-Care Settings, facility policies, manufacturer's recommendations, observations, interviews, and review of employee files, it was determined the facility failed to:

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

2. Use disposable equipment for single use only.

3. Follow their own policy for Contact Isolation.

4. Ensure employees were provided with Hepatitis B options. This affected 1 of 17 employee files and screened annually with a tuberculin (TB) skin test. This affected 3 of 17 employee files. .

5. Ensure that the laboratory followed the policy for proper cleaning of the glucometers before and in between each patient use.

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..."

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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..."

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Policy:
Bedside Glucose Testing
Policy Number #12008
Effective Date: 6/1/14

...Clay County Hospital Laboratory personnel will perform the Bedside Glucose Testing and will perform testing and maintenance according to the procedures in the ACCU-Chek Inform II System Operator's Manual...

ACCU-Chek Inform II System Operator's Manual

Guide to cleaning and disinfecting the ACCU-Chek Inform II System
Page 125

a. Clean the meter to remove visible soil and organic material prior to disinfection.

b. Disinfect the meter to destroy pathogenic and other types of microorganisms. Disinfection destroys most recognized pathogenic microorganisms but not necessarily all microbial forms ( e.g. bacterial spores).

NOTE: The meter should be cleaned and disinfected between each patient use.

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Policy: Reference # 1006a
Tuberculosis Annual Testing
Effective: August 2012

Policy
As recommended by CDC, annual tuberculosis testing will be performed on employees in clinical departments who have direct patient contact and in departments as required by Alabama Department of Public Health which includes:

Nursing Service Units
Laboratory
Respiratory
Radiology
Rehab Services
Food and Nutritional Services

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Policy: Reference # 4022a
Hepatitis B Declination
Revised: 2012

Policy
Employees who have potential exposures to blood and/or other potentially infectious materials while on duty may be at risk of acquiring Hepatitis B virus (HBV) infections. These employees are strongly encouraged to be vaccinated with Hepatitis B vaccine at time of employment.

Employees who decline to receive the Hepatitis B vaccine at time of employment will be asked to sign the "Hepatitis B Vaccine Declination" form. These employees will be informed that in future during their employment at Clay Count Healthcare Authority they may choose to receive the Hepatitis B vaccine.

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Policy: Isolation Precautions
Revised Date: October 2009

Policy:

The "Guideline for Isolation Precautions in Hospitals" has recently been revised. The new guidelines include two levels of precautions:

Standard Precautions:
Precautions, which are designed for care of all patients in facilities, regardless of diagnosis or presumed infection status, to reduce the risk of transmission from both recognized and unrecognized sources of infection.

Transmission Based Precautions:
Precautions, which are designed for care of patients known or suspected of being infected or colonized with epistemologically important pathogens, for which additional precautions beyond Standard Precautions are necessary...

Contact Transmission and Precautions:

Contact transmission is the most important and frequent mode of transmission. Contact transmission is divided into two subgroups:
Direct Contact Transmission - Involves direct body surface to body surface contact with physical transfer of microorganisms between a susceptible host and an infected or colonized person...
Indirect Contact Transmission - Involves contact with intermediate object (usually inanimate) and susceptible host...

Contact Precautions include the following:

Gloves and Handwashing - Wear clean nonsterile gloves as outlined under Standard Precautions, when entering the room. When providing care to the patient, gloves shall be changed after contact with the infective material...
Always remove gloves prior to leaving the patient's environment and wash hands promptly with an antimicrobial agent or a waterless antiseptic agent. Once gloves have been removed and handwashing completed, do not touch potentially contaminated surfaces or items in the patient's room.

Gown - Wear a gown as outlined under Standard Precautions, when entering the room, if you expect that your clothing may come in substantial contact with the patient, surfaces or items in the patient's room... Once the gown has been removed make sure that your clothing does not come in contact with potentially contaminated surfaces.

1. During a tour of the Emergency Department (ED) on 7/8/14 at 10:45 AM with Employee Identifier (EI) # 8 ED Manager, Exam room # 4 was observed to have 3 used Oximetry Sensors (2 adult and 1 pediatric). Two of the sensors were attached to pulse oximetry machines, the other adult sensor was beside the box. These medical supplies were labeled for single patient use only. EI # 8 stated these should have been discarded at the time of patients' discharge.

An interview was conducted on 7/10/14 at 1:35 PM with EI # 8 and the above mentioned findings were verified.



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2. Review of 17 employee files revealed that 3 employees files had no documentation of current TB skin test screening and 1 employee had no documentation of a Hepatitis B titer or declination in the file.

An interview was conducted on 7/10/14 at 2 PM with EI # 1, Administrator, who verified the above mentioned findings.



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3. During a tour of the Laboratory Department on 7/9/14 at 11:00 AM with EI # 13, Laboratory Director, the surveyor observed EI # 14, Laboratory Technician clean two blood glucose monitors and the cases.

During the observation EI # 14 used a Mini Hype-Wipe to clean the glucose monitors. The surveyor observed EI # 14 open a sterile cup and empty excess liquid from the wipe package into the cup. After cleaning the first glucose monitor the surveyor observed EI # 14 placing the used wipe into the cup of solution and squeezed the excess amount of liquid from the wipe. EI # 14 proceeded to clean the second glucose monitor with the wipe. After cleaning the second glucose meter, EI # 14 placed the used wipe in the cup with the solution and squeezed out the excess solution and cleaned both cases for the glucometer.

The surveyor obtained an unopened Mini Hype-Wipe from the Lab Director and read the instructions on the package from the manufacturer, which stated for single use only.

EI # 13 stated the wipes are single use only and asked the surveyor if it was appropriate to dip the used wipe in the extra solution from the wipe package. EI # 13 stated the wipes are too expensive to use a new one each time cleaning the meters in the lab and between each patient.

An interview conducted on 7/10/14 at 9:00 AM with EI #13 confirmed the aforementioned findings.

4. An observation of a medication pass was observed on 7/9/14 at 8:00 AM with EI #15, LPN (Licensed Practical Nurse). EI #15 obtained morning medications for his/her assigned patients. EI # 15 removed the medications for each patient and placed each patient's medications in a cup and marked the cup with the patient's room number and placed all the cups in a single blue drawer. EI # 15 carried the drawer with all the patient's scheduled medications to the rolling computer.

At 9:00 AM EI # 15 was observed dispensing medications to each individual patient. EI # 15 entered each room carrying the blue drawer with all patient's medications into each room.

An interview conducted on 7/9/14 at 10:30 AM with EI # 6, Assistant Director of Nursing, who confirmed the above mentioned and stated the drawer with all the patient's medications should not have been carried into each patient's room.

5. An observation was conducted on 7/10/14 at 8:00 AM on the Medical/Surgical floor to observe wound care provided to a patient with a wound vacuum. Upon arrival to the floor EI # 6 approached the surveyor and explained the wound vacuum dressing had come loose on night shift and the previous shift had already changed the dressing.

After talking with EI # 6, the surveyor asked to see the wound vacuum and check the manufacturer's name. Upon arriving at the patient's room, the surveyor noted a Contact Isolation sign on the patient's door without an isolation cart outside of the door. EI # 6 opened door and the surveyor observed a nursing assistant in the patient's room feeding the patient breakfast. The surveyor observed the nursing assistant did not have on gloves or a gown while feeding the patient.

An interview conducted on 7/10/14 at 8:45 AM with EI # 6, confirmed the above mentioned findings.

Based on the review of the facility's policies and procedures, Operating Room's (OR) temperature and humidity logs, and The Malignant Hyperthermia Association of the United States (MHAUS) requirements, observations and interviews it was determined the facility failed to ensure:

1. The temperatures were monitored for the OR Rooms according to the facility policy

2. The humidity of the OR room and suites were with in range according to the facility's policy.

3. The Malignant Hyperthermia cart was supplied with 36 vials of Dantrolene.

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

Findings include:

Facility Policy: Surgical Services Safety

Keep The humidity at 50 to 55 percent.

Temperature of the operating room will be maintained at 68 to 72 degrees.

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Facility Policy: Management of Patient with Malignant Hyperthermia
Reference # 7020

Subject: Management Of Patient With Malignant Hyperthermia

Procedure:

...Vials are available in the Surgical Services Department, extra vials of Dantrium (Dantrolene) are available in the Pharmacy...

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Malignant Hyperthermia Association of the Untied States:
www.mhaus.org

Drugs:

Therapy should be aimed at prompt treatment of hyperkalemia, administration of dantrolene, hyperventilation, and cooling to target core temperature 38 degrees Celsius.

1. Dantrolene - 36 vials should be available in each institution where Malignant Hyperthermia can occur...

On 7/9/14 at 2:00 PM the surveyor requested the temperature and humidity logs for 2014. On 7/9/14 at 2:15 PM Employee Indentifer (EI) # 3, Surgery Manager, submitted a log with the humidity for OR rooms # 1 and 2. The surveyor asked EI # 3 where the temperature logs were and the response was, "Those are the only logs we have."

Review of the humidity logs for 2014 revealed the following:

Room # 1 = operated 123 days with 89 days out of range humidities (between 56 - 63).

Room # 2 - operated 123 days with 95 days out of range humidities (between 56 - 65).

An interview was conducted with EI # 3 on 7/9/14 at 2:45 PM. EI # 3 verified the above findings.

Review of the Malignant Hyperthermia cart on 7/9/14 at 2:00 PM, revealed 24 vials of Dantarolene. The surveyor asked EI # 3 where the other 12 vials of Dantrolene were and the response was, "Probably in the Pharmacy".

An interview was conducted on 7/9/14 at 2:30 PM with EI # 4, Director of Pharmacy. EI # 4 stated there was no Dantrolene in the pharmacy and all the hospital had was in the Surgical Department.

Based on the review of the facility policy and outpatient medical records and interview, it was determined the facility failed to ensure the History and Physical were completed 30 days prior to surgery in 2 of 2 records with cataract surgery. This affected Outpatient Indentifer (OI) # 2 and 3 and had the potential to affect all patients served by this facility.

Findings include:

1. OI # 2 was admitted to Outpatient on 6/13/14 for Cataract Surgery with Placement of an Intraocular Lens.

Review of the History and Physical revealed a date of 5/9/14, which was 35 days before the surgery on 6/13/14.

2. OI # 3 was admitted to Outpatient on 4/11/14 for Cataract Surgery with Placement of an Intraocular Lens.

Review of the History and Physical revealed a date 0f 2/14/14, which was 55 days before the surgery on 4/11/14.

An interview was conducted on 7/9/14 at 2:00 PM with Employee Indentifer # 1, Administrator, who verified the above findings.