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Based on the review of the facility's Performance Improvement Plan for 2012, Quality Meeting Minutes for 2015, Occurance reports, policies and procedures and interviews, it was determined the facility failed to ensure the Performance Improvement Committee:

Refer to A 57 for findings

A. Identified and resolved problems related to patient care.
Refer to A 283

B. Adopted polices supporting a non-punitive approach to staff reporting of medical error, adverse events and situations the staff considered unsafe. Refer to A 286

C. Had a hospital-wide and documented system of quality assessment and performance improvement program.
Refer to A308


Based on review of the Controlled Substance Count sheets, medical records, Center for Disease Control (CDC) Guidelines, Formulary and facility policy and interview, it was determined the facility failed to ensure:

1. The controlled substance count was correct for Morphine Sulfate. Refer to A 494

2. The staff followed their own policies for patients home medications. Refer to A 501

3. Supplies available for patient use were not expired. Refer to A 505

4. Single use vials were used for a single procedure. Refer to A 505

5. Medications available for patient use were not expired. Refer to A 505

6. Multi use vials were labeled with the date, time and person who opened the vial. Refer to A 505

7. The Pharmacy Department followed their own policy for review of the Formulary. Refer to A 511

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

Based on the review of the facility's Performance Improvement Plan for 2012, Quality Meeting Minutes for 2015, Occurance reports, policies and procedures and interviews, it was determined the facility failed to ensure the Performance Improvement Committee:


A. Identified and resolved problems related to patient care.
Refer to A 283

B. Adopted polices supporting a non-punitive approach to staff reporting of medical error, adverse events and situations the staff considered unsafe. Refer to A 286

C. Had a hospital-wide and documented system of quality assessment and performance improvement program.
Refer to A308


Based on review of the Controlled Substance Count sheets, medical records, Center for Disease Control (CDC) Guidelines, Formulary and facility policy and interview, it was determined the facility failed to ensure:

1. The controlled substance count was correct for Morphine Sulfate. Refer to A 494

2. The staff followed their own policies for patients home medications. Refer to A 501

3. Supplies available for patient use were not expired. Refer to A 505

4. Single use vials were used for a single procedure. Refer to A 505

5. Medications available for patient use were not expired. Refer to A 505

6. Multi use vials were labeled with the date, time and person who opened the vial. Refer to A 505

7. The Pharmacy Department followed their own policy for review of the Formulary. Refer to A 511

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

Based on the review of the facility's Performance Improvement Plan for 2012, Quality Meeting Minutes for 2015, Occurance reports, policies and procedures and interviews, it was determined the facility failed to ensure the Performance Improvement Committee:


A. Identified and resolved problems related to patient care.
Refer to A 283

B. Adopted polices supporting a non-punitive approach to staff reporting of medical error, adverse events and situations the staff considered unsafe. Refer to A 286

C. Had a hospital-wide and documented system of quality assessment and performance improvement program.
Refer to A308


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

Based on the review of the facility's 2012 Continuous Quality Assurance Organizational Plan, Occurrence Reports for 2014 and interview, it was determined the facility's Continuous Quality Assurance (CQA) Committee failed to:

A. Identify and resolve problems related to patient care.

B. Track performance to ensure that improvements are made and problems identified.

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

Findings include:

1. Refer to A 308 for 2012 Continuous Quality Assurance Organizational Plan

2. 4 Occurrence Reports were given to the surveyor dated 2/28/14, 4/24/15 and 2 of the 4 did not have the date documented.

The facility failed to include any identified problems, interventions or resolutions for 2014 to the surveyor upon request.

In an interview conducted 2/27/15 at 9:30 AM with Employee Identifier (EI) # 1, Director of Nursing, the surveyor requested CQA Committee minutes and CQA plan for 2014. EI # 1 only presented CQA for 1/2015 and 2/2015.

Based on the review of the facility's policies and procedures and interviews, it was determined the facility failed to adopt polices supporting a non-punitive approach to staff reporting of medical error, adverse events and situations the staff considered unsafe. This had the potential to affect all patients served by this facility.

Findings include:

During a review of the facility's policies and procedures on 2/26/15 at 9:30 AM, the surveyor was unable to find a policy on a non-punitive approach to staff reporting of medical errors (including near misses/close calls), adverse events and situations the staff considered unsafe.

An interview was conducted on 2/26/15 at 10:00 AM with Employee Identifier (EI) # 4, Registered Nurse (RN) and EI # 7. During the interview the surveyor asked EI # 7 "what would you do if EI # 4 was about to administer the wrong dose of Potassium to a patient"? EI # 7 stated he would tell EI # 4. The surveyor asked if there was anything else he/she should do and the response was "no". The surveyor asked EI # 7 if he/she would report the incident as a "near miss" and the response was "no". The surveyor asked EI # 7 why his/her response was no and the reply was "because he/she might get in trouble".

In an interview conducted 2/26/15 at 9:30 AM with EI # 1, Director of Nursing, the surveyor requested the policy on a non-punitive approach to staff reporting of medical errors (including near misses/close calls), adverse events and situations the staff considered unsafe. EI # 1 was unable to submit a policy.

Based on review of the 2012 Continuous Quality Assurance (CQA) Plan, interview and 2015 CQA meeting minutes, it was determined the facility failed to ensure the CQA Committee was hospital-wide. This had the potential to affect all patients served by this facility.

Findings include:

Facility's 2012 Performance Improvement Plan

"1. Purpose:
To provide the patients of J. Paul Jones Hospital with the highest quality patient care within the capabilities of the hospital and to continually evaluate quality and appropriateness of care and clinical performance found in the patient care process.

2. Goals:
a. Maintain an ongoing review of patient care within the institution with the aim of promoting and maintaining optimal patient care through analysis, review and evaluation of clinical practice and hospital polices.

b. To identify potential and actual problems as efficiently and quickly as possible.

c. To improve communication between all departments of the hospital.

d. To improve the overall organization of patient care at this facility.

e. To provide documentation as evidence of an ongoing CQA (Continuous Quality Assurance) plan that includes effective mechanisms for reviewing and evaluating patient care and for appropriate response to findings.

3. Organization: Hospital Wide
All organized services will participate in the CQA program. This will include the following departments:

a. Medical Advisor
b. CQA Coordinator
c. Nursing Services
d. Radiology
e. Medical Records
f. Housekeeping (Environmental Services)...
h. Dietary
i. Pharmacy
j. Utilization Review

Respiratory (part of Nursing Services) and Laboratory departments conduct their own CQA meetings apart from the above departments. ...

The following areas should be addressed:
a. Patient care problems
b. Cause of the problem
c. Documented corrective action
d. Evaluation of the effectiveness of the actions taken

Objective collection of information in all aspects of patient care is essential in the identification of potential and actual problems in the care of patients. The cause and scope of the potential/actual problems and/or problems. Monitoring tools should be in place to assure the desired result has been achieved and maintained. There should be documentation which substantiates the effectiveness of the overall program to enhance patient care and to assure sound clinical performance...

Written criteria that relate to essential or critical aspects of care and that are generally acceptable to the clinical staffs will be used to assess problems and measure compliance with achievable goals. These criteria are to be clinically valid.

Appropriate written action will be implemented to eliminate or reduce the identified problems. Actions may include, but are not limited to education and training programs, new or revised policies or procedures, staffing changes, equipment or facility change, or adjustments in clinical privileges. Periodic monitoring of the results of the corrective action will be conducted to assure the identified problems have been eliminated or satisfactorily reduced.

Responsibilities In CQA

1. Governing Body and Administration

In order to fulfill their responsibility to patients and professional staff and to the community served, the Governing Body and Administration has approved this CQA plan, to be reviewed and revised as needed. It is designed to objectively and systematically monitor and evaluate the quality and appropriateness of patient care, to continually pursue opportunities to improve patient care, and identify and resolve problems. The Governing Body and Administration will support CQA activities within the hospital by assuming responsibility for the ongoing CQA program and by acting on findings or recommendations related to action implemented. It will also give authority and accountability for the operation of the program to the CQA Committee.

The CQA Committee will be composed of the following:

a. CQA Physician Advisor
b. CQA Coordinator (Director of Nursing)
c. Radiology Director
d. Medical Records Director
e. Pharmacy...
g. Housekeeping
h. Dietary Department Head

Infection control will be addressed by all departments, ...

A physician member of the Medical Staff will serve as advisor to the CQA Committee. ...

2. CQA Coordinator

One person shall serve as CQA Coordinator. At J. Paul Jones Hospital this person will be the Director of Nursing since he/she works closely with all departments within the facility. The CQA Coordinator will assist the medical, nursing, and professional staffs in the development of criteria and appropriate tools to assess the quality and appropriateness of patient care.
...

3. Department Heads

Each professional staff will be responsible for identifying and resolving related to the patient care they provide. Each department head will be responsible for documentation of identified problems, corrective actions, and evaluation of the actions taken to correct the identified problems.

4. Patients

Patients are also involved in CQA by having the opportunity to complete patient satisfaction surveys. These surveys are sent to each inpatient after discharge. Randomly selected Emergency Room patients are sent surveys. These surveys address the various aspects of patient care and contain a self-addressed, stamped envelop to encourage the patients to complete and return them to our facility.

5. Evaluation Of The CQA Program

The plan will be evaluated on an ongoing basis and will be reviewed annually and revised if necessary by the CQA Committee.

The CQA Coordinator will be responsible for preparing a report for the annual review using source documentation:

a. Minutes for the CQA meetings
b. Problem focused studies
c. Monitoring reports
d. Any reports or formats deemed appropriate by the CQA Coordinator or the CQA Committee as a whole".

Review of the CQA meeting minutes for 1/13/15 failed to include the following departments: Pharmacy,Medical Records, Radiology and Laboratory.

Review of the CQA meeting minutes for 2/5/15 failed to include the following departments: Pharmacy, Radiology, Housekeeping, Medical Advisor and Laboratory.

There was no documentation included in the minutes which identified any patient care problems, cause of the problems, documented corrective action or evaluation of the effectiveness of action taken.

A request was made on 2/26/15 at 9:30 AM for Employee Identifier # 1, Director of Nursing/CQA Coordinator, to provide the data and analysis from quality indicators selected for the CQA program for the year 2014.

An interview conducted with Employee Identifier # 1, Director of Nursing, on 2/26/15 at 10:15 AM verified the CQA plan had not been updated or reviewed since 2012. EI # 1 was unable to provide the Quality Assessment Performance Improvement for the year 2014.

Based on observation, record review, and review of policies and procedures it was determined the facility failed to ensure:

1. Patients received all ordered medication.
2. Wound assessments were conducted.
3. Wound care was provided according to the physician's orders.
4. Staff correctly provided a bed bath per facility policy.

This affected Medical Record (MR) # 3, 1 of 1 MR's with a pressure ulcer, MR # 6, 1 of 1 patients observed requiring a bed bath, and MR # 7, 1 of 3 patients observed for medication administration, and had the potential to negatively affect all patients served by the facility.

Findings include:

"Policy: Hand Hygiene
Condition of nails and hands

Fingernails should be short (no longer than 1/4 inch above the fingertip) and clean
Direct care healthcare providers will not wear artificial nails or extenders..."

Policy: "Bedbath
Effective Date- 1/1/85
...General Instructions:...
2. Change water when it becomes cool or soapy and as needed.
3. Remove all soap as it is drying and irritating to skin. ...
...Procedure:...
16. Place bath towel underneath the heel and flexed leg; place bath basin on towel.
17. Place foot in basin and wash. Raise foot and remove basin. Put foot on towel and dry. Clean toe nails if necessary.
18. Drape and wash opposite leg and foot in same manner.
19. Get clean water.
...23. b. If patient is unable to finish bath, have patient flex knees. Place towel under buttocks lengthwise. Lift sheet from side and bathe area between thighs using gentle downward strokes. Dry well using end of bath towel. Have patient turn from side away from you..."

********

1. An observation of a medication pass was conducted on 2/25/15 at 8:15 AM. The surveyor observed Employee Identifier (EI) # 4, Registered Nurse (RN) prepare medications for MR # 7. This medications included: Duoneb, Clonidine, Hydralazine, Telamlo, Mobic and Diltiazem. Review of the physician orders dated 2/23/15 revealed an order for Levetiraceta (seizure medication) twice a day. Review of the Medication Charge Sheet dated 2/24/15 revealed the patient only received Levetiraceta once, instead of twice as ordered. Review of the Medication Charge Sheet dated 2/25/15 revealed no documentation of Levetiraceta and none was administered during the medication pass.

An interview was conducted with EI # 4 2/25/15 at 10:30 AM who verified the above findings.




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2. MR # 3 was admitted to the facility 10/17/14, from a nursing home, with a diagnosis of Decubitus Ulcer to Left Ischium Stage III.

Review of the physician's orders included to perform a culture and sensitivity (C&S) of the wound to the left Ischium and perform wet to dry daily dressing changes.

Review of the skilled nurse documentation dated 10/17/14 at 6:46 PM revealed the following documentation: "wound culture was obtained from wound on left buttocks--cleansed and wet/dry dressing applied--covered with abd (abdominal) pad and secured with tape". There was no documentation of what cleanser the skilled nurse used. There was no documentation the physician was contacted for an order for wound cleanser or abd pad and tape.

There was no documentation included in the skilled nurse assessment of a wound assessment or measurements.

Continued review of the skilled nurse documentation revealed 10/18/14 at 6:45 AM the following: "Affected area to the left lower buttock was cleansed with normal saline and wet to dry dressing applies and secure with retention tape". There was no documentation of a physician's order for normal saline or retention tape.

Again on 10/19/14 at 6:27 AM the skilled nurse documented the following: "Soiled dressing removed from left lower buttocks. Wet to dry dressing applied and secured with retention tape". There was no documentation of a physician's order for retention tape.

On 10/20/14 at 6:03 AM the skilled nurse documented " soiled dressing removed from left lower buttock. Pus and strong odor noted to affected area". There was no documentation the wound care was performed or the wound was assessed.

There was no documentation the physician was notified of the purulent drainage or strong odor noted from the wound.

There was no further documentation the wound care was performed after 10/19/14 at 6:27 AM.

At 7:06 PM on 10/21/14 the patient was transferred back to the nursing home from which the patient came.

An interview with EI # 1, Director of Nursing (DON), on 2/27/15 at 9:30 AM verified the aforementioned findings. EI # 1 was asked for a policy on wound care assessment and wound care. The surveyor was provided a "Skin Condition Record for Non-Pressure Ulcer Skin Conditions". EI # 1 stated there was no policy for wound assessment or wound care.

2. MR # 6 was admitted to the facility 2/23/14 with a diagnosis of Syncope.

An observation was conducted on 2/26/15 at 10:25 AM of EI # 5, Certified Nurse Aide (CNA), to provide a complete bed bath to MR # 6.

EI # 4 was assisting EI # 5 with helping to turn the patient as needed. EI # 5 obtained a bath pan with water and placed at the bedside, EI # 5 washed hands and donned clean gloves.

EI # 5 bathed patient's face with a soapy bath cloth and dried with towel. Discarded the bath cloth.

EI # 5 obtained a clean bath cloth and bathed the patient's upper body and extremities with soap, disposed of the bath cloth, dried skin with towel.
EI # 5 removed gloves, washed hands and donned clean gloves.

EI # 5 obtained a clean bath cloth and bathed the patient's lower extremities with soap and dried. After bathing lower extremities EI # 5 removed gloves, washed hands and donned clean gloves.

EI # 5 obtained a clean bath cloth and using the same water and bar soap, EI # 5 bathed the perineal area. After EI # 5 completed bathing the perineal area and disposing of the bath cloth, EI # 4 asked EI # 5 to get a clean cloth and rinse the perineal area.

EI # 5 then used a clean bath cloth and with instructions from EI # 4 continued to perform catheter care as instructed.

EI # 5 then rolled the patient to the left side to complete the bath and bathed the patient's back, buttocks, and anal area.

EI # 5 did not change the water during the bed bath or rinse the soap off the patient.

An interview with EI # 4, RN, after the bedbath was completed on 2/26/15 at 10:55 AM confirmed the above findings.

Based on record review and interview, it was determined the facility failed to have completed Emergency Room (ER) records to include Disposition of Care, Condition on Discharge and Indicating if it was a Certified Emergency. This affected ER # 5, ER # 6, and ER # 14 (3 of 15 ER records reviewed) and had the potential to affect all patients served by this ER facility.

Findings include:

1. ER # 14 was seen in the ER on 10/6/14 due to an assault. Review of the ER record revealed no documentation of Condition on Discharge.

2. ER # 6 was seen in the ER on 8/31/14 due to an insect bite. There was no documentation of Disposition of Care, Condition on Discharge or if this was a Certified Emergency.

3. ER # 5 was seen in the ER on 9/23/14 with a dog bite. Review of the ER record revealed no documentation of Condition on Discharge or if this was a Certified Emergency.

An interview was conducted on 2/24/15 at 3:30 PM with Employee Indentifer (EI) # 7, Assistant Director of Nurses. EI # 7 verified the above findings.

Based on review of the Controlled Substance Count sheets, medical records, Center for Disease Control (CDC) Guidelines, Formulary and facility policy and interview, it was determined the facility failed to ensure:

1. The controlled substance count was correct for Morphine Sulfate. Refer to A 494

2. The staff followed their own policies for patients home medications. Refer to A 501

3. Supplies available for patient use were not expired. Refer to A 505

4. Single use vials were used for a single procedure. Refer to A 505

5. Medications available for patient use were not expired. Refer to A 505

6. Multi use vials were labeled with the date, time and person who opened the vial. Refer to A 505

7. The Pharmacy Department followed their own policy for review of the Formulary. Refer to A 511

This had the potential to affect all patients served by the facility

Based on review of the Controlled Substance Count sheets and facility policy and interview, it was determined the facility failed to ensure the controlled substance count was correct for Morphine Sulfate. This had the potential to affect all patients served by the facility.

Findings include:

Facility Policy: Pharmacy
# 15-06

Policy:

A complete and accurate inventory of all controlled substances shall be taken as required by federal and state law as well as CHS (Community Health Systems) Corporate Substances Policies.

Required Inventories:

...Pharmacy vault inventory...must be conducted each month and verified by two licensed professionals.

A controlled substance count was conducted with Employee Indentifer (EI) # 3, Pharmacist, on 2/25/15 at 9:40 AM in the pharmacy. Morphine Sulfate 2 mg (milligrams)/ml (milliliter) was counted and 61 were in the controlled substance cabinet. Review of the Controlled Substance Count sheet revealed there should have been 59 instead of the 61.

Morphine Sulfate 4 mg/ml was counted and there were 39 in the controlled substance cabinet. Review of the Controlled Substance Count sheet revealed there should have been 69 instead of the 39 counted in the cabinet.

An interview was conducted with EI # 1, Director of Nurses on 2/25/15 at 11:15 who submitted 3 Records of Administration of Narcotics for 4 mg/ml Morphine sulfate dated 8/1/14 and two 1/22/15. Each sheet contained 10 Morphine Sulfate 4 mg/ml which accounted for the 30 missing Morphine Sulfate 4 mg/ml.

The Morphine Sulfate 4 mg/ml count has been incorrect since 8/1/14. An interview was conducted with EI # 1 on 2/25/15 at 11:15, who verified the above findings.

Based on review of the facility's policies and medical records, interview and observation, it was determined the facility failed to follow their own policies for patients home medications. This affected Medical Record (MR) # 7 and MR # 10 (2 of 2 patients who were administered their medications from home) and had the potential to affect all patients served by this facility.

Findings include:

Facility Policy: Pharmacy

Policy:

A patient's personal drugs shall only be administered to the patient upon the order of the patient's physician...

Retention of Personal Drugs in the Facility

Unless administration of a patient's personal drugs is authorized by the responsible prescribing practitioner, these drugs shall be sent home with the family or others. If the drugs must be retained in the facility, they shall be packaged, sealed, labeled with the patient's name, maintained in lock storage...

Identification of Patients' Personal Drugs

Drugs brought into the facility by patients shall not be administered unless the drugs have been absolutely identified, their quality and integrity is not questionable, and there is a written order from the responsible prescribing practitioner to administer the drugs.

Identification of a patient's personal drugs must be by the attending physician, another responsible prescribing practitioner, or a pharmacist.

1. MR # 7 was admitted to the facility on 2/23/15 with diagnoses including Left Lower Pneumonia with Left Pleural Effusion and End Stage Renal Disease.

An observation of a medication pass was made on 2/25/15 at 8:15 AM with Employee Indentifer (EI) # 4, Registered Nurse. EI # 4 prepared medication for MR # 7 which included Tekamlo 300/5. EI # 4 stated that this was one of the patient's medication from home since the hospital did not have Tekamlo. The surveyor ask to see the documentation the attending physician, another responsible prescribing practitioner, or a pharmacist had identified the medication. EI # 4 stated there was no documentation.

Review of the physician's orders revealed no documentation of an order for the staff to administer the home medication.

2. MR # 10 was admitted to the facility on 2/19/15 with diagnoses including Pneumonia.

An observation of a medication pass was made on 2/25/15 at 8:30 AM with EI # 4. EI # 4 prepared medication for MR # 10 which included Advair Inhaler. EI # 4 stated that this was one of the patient's medication from home since the hospital did not have Advair. The surveyor ask to see the documentation the attending physician, another responsible prescribing practitioner, or a pharmacist had identified the medication. EI # 4 stated there was no documentation.

An interview was conducted with EI # 3, Pharmacist on 2/25/15 at 11:00 AM, who verified the above findings.

Based on review of the Center for Disease Control (CDC) Guidelines, observation and interview, it was determined the facility failed to ensure:

A. Supplies available for patient use were not expired
B. Single use vials were used for a single procedure
C. Medications available for patient used were not expired
D. Multi use vials were labeled with the date, time and person who opened the vial.

This affected Medical Record (MR) # 7 and had the potential to affect all patients served by this facility.

Findings include:

"Basic Safe Injection Practice Messages by the CDC

CDC evidence-based guidelines define safe injection practices under Standard Precautions. These include one-time use of needles and syringes and limiting sharing of medication vials. Vials labeled as " single dose " or " single use " should not be used on multiple patients.
A large single-dose/single-use vial may appear to contain adequate drug to treat more than one patient. However, single-dose/single-use vials typically lack antimicrobial preservative and can become contaminated and serve as a source of infection when they are used inappropriately. Therefore, they should only be used for a single patient and a single procedure.

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.

A tour of Emergency Room # 3 was conducted on 2/24/15 at 9:50 AM. The following supplies were identifed as out of date:

1. Female Fast Catherzation (7) expired 12/2014
2. Urethral Catherzation Tray 14 French expired 06/2012
3. Lubercating Jelly 3 grams (48) expired 05/2012
4. Foley Catherter 18 french expired 2014
5. Povidone Iodine 1 swab stick (4) expired 6/2013
6. Stylet Large expired 03/2013
7. Povidone Iodine 3 swab sticks (2) expired 6/2013
8. Chloroprep 1 swab expired 08/2010
9. Chloroprep 1 swab expired 06/2010
10. Chloroprep 1 swab expired 02/2012

A tour of the hospital was conducted on 2/24/15 at 10:05 AM. During the tour, observation of the crash cart was conducted. The following items were identified as out of date:

1. Quad Lumen Central Venous Catheter Kit (1), expired 10/13
2. 3 cc (cubic centimeter) Lure syringe (5), expired 1/15
3. Yanker Suction (2), expired 4/10 and 1/13
4. Stylette 14 g (gauge), 1.75" (inches) length, (5), expired 1/14
5. Stylette 18 g, 1.88", (1), expired 12/06

An observation of medication passes was conducted 2/25/15 at 9:10 AM with Employee Indentifer (EI) # 4, Registered Nurse (RN). The surveyor observed EI # 4 obtain a 50 ml (milliliter) single use vial of 0.9% Sodium Chloride which was dated as being opened on 2/24/15 at 11:15. The cap was off the vial. EI # 4 obtained a syringe and withdrew 3 cc (cubic centimeters). EI # 4 went to MR # 7 room and flushed the patient's saline lock (Intravenous access) with the 3 cc of saline.

An interview was conducted on 2/25/15 at 9:15 AM with EI # 4. The surveyor asked EI # 4 if the 50 ml vial of Sodium Chloride was a multi use vial and the response was, "no it was a single use vial and should not have been used".

A tour of the nurse's medication room conducted on 2/25/15 at 9:30 AM with EI # 1, Director of Nurses. The surveyor observed the following 10 ml insulin multi dose vials open and not labeled Humulin R, Humalog 75/25, and Humalog. The surveyor observed a 10 ml bottle of Novolog which had a label stating it was opened 9/11/14, which is 5 months. There was ten 0.7 ml. of diluent which expired 6/2014.

An interview was conducted with EI # 1 on 2/25/15 at 9:45 AM, who verified the above findings.

A tour of the pharmacy was conducted on 2/25/15 at 9:40 AM with EI # 3, Pharmacist. The surveyor observed a 30 ounce bottle of Miralax which expired 1/2015. EI # 3 verified the Miralax had expired.

Based on the review of the Formulary and hospital policy and interview, it was determined the hospital failed to follow their own policy for review of the Formulary. This had the potential to affect all patients served by this hospital.

Findings include:

Facility Policy: Formulary System
# 08-02

Review and Revision of the Formulary

"The Director of Pharmacy shall maintain the formulary as a current document. The Director shall review the formulary routinely (preferably annually) and update it as necessary. The medical staff shall document its review and acceptance of the updated formulary".

Review of the Formulary revealed the last date of review was April 2011, which was 4 years.

An interview was conducted with Employee Identifier (EI) # 3, Pharmacist, on 2/25/15 at 10:00 AM. EI # 3verified the above findings.

Based on the review of the Dietary Manual and interview, it was determined the facility failed to ensure the Dietary Manual was:

1. Reviewed by the Medical Director and Registered Dietician yearly

2. No more than 5 years old.

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

Findings include:

Review of the Dietary Manual revealed the last date the Medical Director and the Registered Dietician reviewed the Manual was in 2010. Further review of the Dietary Manual revealed a copyright date of 1993, which had been 22 years.

An interview with Employee Identifier (EI) # 1, Director of Nurse was conducted on 2/25/15 at 11:00 AM. EI # 1 verified the above findings.

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 review of facility policies and procedures, observation and interview with administrative staff, it was determined the facility failed to ensure the staff followed their own policies for hand hygiene.

This affected MR # 6, MR # 7 and MR # 10 and had the potential to negatively affect all patients served by the facility.

Findings Include:

"Policy: Hand Hygiene"

"... Procedures: Hand Hygiene should occur in the following situations:

When hands are visibly dirty or contaminated.

Following contact with a patient's intact skin.

After contact with body fluids or excretions, mucous membranes, non-intact skin or dressings.

If moving from a contaminated body site to a clean body site during patient care. ...

Before donning gloves when performing surgical procedures.

Before inserting indwelling urinary catheters or other invasive devices that do not require a surgical procedure.

After removing gloves. ...

Hand Hygiene Techniques

Soap and water
...
Rinse hands thoroughly under running water.

Dry hands with paper towel.

Use paper towel to turn off the water faucet. ..."

**********

Facility Policy:" Cleaning, Disinfection and Sterilization

Non-critical patient care items are cleaned and disinfected between patients".

**********

Facility Policy: "Infection Control

Procedure 4 and 5.

Plastic sharps containers, or approved corrugated containers are used in all locations for quick access...Follow containers instructions..."

An observation of care was conducted on 2/25/15 at 8:15 AM. Employee Identifier (EI) # 4, Registered Nurse (RN) prepared MR # 7's medication with gloves. During the preparation EI # 4 realized some medications were in the pharmacy. EI # 4 removed gloves and entered the pharmacy without performing hand hygiene.

EI # 4 placed all of MR # 7's medication on the tray and entered MR # 7's room. EI # 4 placed the tray of medication on the patient's bedside table. EI # 4 took the empty tray, after medications were administered back into the medication room and placed the tray on the clean counter.

EI # 4 then began preparing MR # 10's medications. EI # 4 placed the patient's medication on the same tray, removed gloves without hand hygiene, picked up the tray and entered MR # 10's room. EI # 4 placed the tray on the patient's bedside table. EI # 4 failed to disinfect the tray between entering patients' rooms.

During the medication passes the surveyor observed the sharps container was overfilled approximately 2 inches above the manufacture's indicated full line.

During medication passes to MR # 6, MR # 7, and MR # 10 on 2/25/15 between 8:15 to 9:30 AM, the surveyor observed EI # 4 wash his/her hands 5 times. Each time after hands were washed, he/she turned the faucet off without a barrier before drying his/her hands.

Based on review of Medical Records (MR), "Patient Rights, Freedom of Choice in Selecting A Home Health or Hospice Provider" form, and interview, it was determined the facility failed to offer a preference for home health to patients discharged needing home health services.

This affected MR # 4, MR # 8, and MR # 9, 3 of 3 MR'S reviewed with home health referrals and had the potential to negatively affect all patients discharged requiring home health services.

Findings Include:

Review of the "Patient Rights, Freedom of Choice in Selecting A Home Health or Hospice Provider" form, revealed a statement as follows: "According to federal regulations, patients are to be given freedom of choice in selecting a certified Home Health Agency, Hospice, or Durable Medical Equipment (DME) provider. The following agencies are authorized to provide services in Wilcox County. Please choose an agency and sign this form to indicate that you have selected the agency of your choice. If an authorized individual is signing on behalf of the patient, please disclose the relationship to the patient".

There were 10 different "Certified Home Health Agencies" listed and a space to write in a specific named Home Health if requested.

There were also 12 different "Certified Hospice Agencies" listed and a space to write in a specific named Hospice if requested.

There was no DME companies listed.

The bottom of the form included a space for signatures, date and witness.

1. MR # 4 was admitted to the facility 12/08/14 with diagnosis of Bilateral Lower Lobe Pneumonia and discharged 12/16/14. Review of the discharge assessment form failed to include documentation the patient was to have home health upon discharge.

Review of the physician's order dated 12/16/14 revealed the following: Discharge to "Alabama Home Care". Documentation (unidentifiable signature) dated 12/16/14 in the progress note revealed the following: "Home today-Refer to Home Health-See orders".

There was no preference form included in the medical record. There was no documentation the patient or caregiver was asked of a preference. There was no documentation the Home health agency was contacted.

An interview conducted on 2/27/15 at 10:15 AM with Employee Identifier (EI) # 1, Director of Nursing (DON), verified there were no preference forms given, no discussion documented with the patient/caregiver or contact made to the referring home health agency.


2. MR # 8 was admitted to the facility 7/6/14 with diagnoses including Alzheimer Disease and Acute Renal Failure and discharged 7/12/14.

Review of the "Discharge Planning" intake form revealed the patient planned to "go back home with son who is her primary caregiver and assistance of Alabama Tombigbee".

The "Discharge Planning" intake form contained the following statement:
"Discharge plan has been discussed with caregiver. Yes ...If the answer is yes please have caregiver and discharge planning coordinator sign below".

There was no signature, date or time included on the form.

Review of the "Discharge Assessment Form" dated 7/12/14 included the following documentation: "D/C (discharge) to Home, Nursing Home" (both were marked) "...Other instructions: Alabama Home Care will come out to set up home health services..."

There was no documentation discussion was conducted with the patient/caregiver regarding which home health was preferred.

There was no documentation a preference form was given to the patient/caregiver.

There was no documentation the Home Care agency was notified.

There was no documentation the Alabama Tombigbee Home care agency was notified of the change in home health agencies.

An interview conducted on 2/27/15 at 10:15 AM with EI # 1, verified there were no preference forms given, no discussion documented with the patient/caregiver or contact made to the referring home health agency.


3. MR # 9 was admitted to the facility 9/16/14 with diagnose including Congestive Heart Failure (CHF), Acute Urinary Track Infection (UTI), Hypertension (HTN) and Diabetes Type II.

Review of the physician's order revealed the following: Discharge to "Alabama Home Care".

Review of the "Discharge Assessment Form" dated 9/18/14 included the following documentation:"...Alabama Home Care will come out tomorrow to admit..."

There was no documentation discussion was conducted with the patient/caregiver regarding which home health was preferred.

There was no documentation a preference form was given to the patient/caregiver.

There was no documentation the home health agency was notified of the referral.


An interview conducted on 2/27/15 at 10:15 AM with EI # 1, verified there were no preference forms given, no discussion documented with the patient/caregiver or contact made to the referring home health agency.

EI # 1 stated, "The doctor writes the order with the home health agency he/she prefers and that is who we send the referral to".