HospitalInspections.org

Based on review of the hospital QAPI (Quality Assurance and Performance Improvement) program documentation, hospital policy and interviews, it was determined the hospital QAPI program failed to include the pharmacy department.

This had the potential to negatively affect all patients admitted to the hospital.

Findings include:

Hospital Policy: QAPI Plan.
Policy Number: Not documented.
Reviewed Date: 3/16/23.

Purpose: ...The QAPI Program promotes the mission of J. Paul Jones Hospital by establishing a formal, organization-wide system to continually monitor and evaluate quality of care....

...Scope:

The QAPI Plan encompasses all services of J. Paul Jones Hospital...

1. Review of the facility QAPI program was conducted on 7/7/23 at 9:46 AM with Employee Identifier (EI) # 2, Director of Nursing. Review of the facility QAPI Program revealed no documentation the pharmacy department reported data into the facility QAPI program.

During the review of the facility QAPI program, EI # 2 verbalized the pharmacy department has not reported data to the facility QAPI program since before "COVID."

Based on MR (medical record) reviews, Lippincott Manual of Nursing Practice, National Institutes of Health, Nursing Fundamentals and staff interviews it was determined the hospital failed to ensure the facility:

1. Formulated a policy and/or procedure for pain assessment, reassessment, and adjustment of the pain plan.

2. Staff documented a comprehensive pain assessment and reassessment.

3. Staff documented blood sugar monitoring per the physician's orders.

4. Staff administered sliding scale insulin per the physician's orders.

5. Staff documented a comprehensive wound assessment.

This deficient practice did affect five of nine inpatient MRs reviewed with a complaint of pain, including Patient Identifier (PI) # 18, PI # 21, PI # 26, PI # 28, and PI # 27 and two of four inpatient MRs reviewed with orders for blood sugar monitoring and sliding scale insulin, including PI # 23, PI # 24 and had the potential to negatively affect all patients admitted to the hospital.

Findings include:

Lippincott Manual of Nursing Practice, 11th Edition.
Date: 2019

...Appendix D: Pain.
Guide to General Pain Management.

...Pain Assessment.

1. Screen for pain at each visit. Evaluate objectively the nature of the patient's pain, including location, duration, quality, and impact on daily activities...

a. Explore pain interventions that have been used and their effectiveness.
b. Determine whether the intensity of the pain correlates with the prescribed analgesic.

...3. Use a pain intensity scale of 0 (no pain) to 10 (worst possible pain) or other pain scale as appropriate...

4. Assess relief from medications and duration of relief. (Use the same measuring scale every time.) Reevaluate the pain frequently...

National Institutes of Health, Nursing Fundamentals.
Date: 2021

Chapter 10 Integumentary

Table 10.6 b...Wound assessment

Wound Assessment:

Type... It is important to understand the type of wound present to select appropriate interventions.

Location... The location of the wound should be documented precisely...

Size... Wound size should be measured... Length...Width...If tunneling or undermining is present...Depth...

Degree of Tissue Injury...Wounds are classified as partial-thickness...or full thickness...for pressure injuries, it is important to assess the stage of the injury...

Color of Wound Base... Assess the base of the wound for the presence of healthy, pink/red granulation tissue...dark red granulation tissue, white or yellow slough, or brown or black necrotic tissue.

Drainage... The color, consistency, and amount of exudate (drainage) should be assessed and documented...

Signs and symptoms of infection... Assess for signs and symptoms of infection...

Wound edges and periwound... Assess the surrounding skin for maceration or signs of infection.

Pain... Assess for pain in the wound or during dressing changes...

1. PI # 18 was admitted to the hospital on 6/5/23 with diagnoses including Syncopal Episode.

Review of the nursing notes dated 6/6/23 revealed:

At 1:00 AM, the nurse documented the patient complained of feeling a "little sore." There was no documentation of the location of the soreness, pain intensity, quality, aggravating and alleviating factors.

At 12:15 PM, the nurse documented the patient complained of right ankle pain. There was no documentation of the pain intensity, quality, aggravating and alleviating factors.

Review of the nursing notes dated 6/7/23 revealed:

At 8:00 PM, the nurse documented the patient complained of right foot/ankle pain. There was no documentation of the pain intensity, quality, aggravating and alleviating factors.

At 10:00 PM, the nurse documented the patient complained of generalized aches/pains. There was no documentation of the pain intensity, quality, aggravating and alleviating factors.

Review of the MR revealed no documentation a pain plan for the patient had been developed.

An interview was conducted, via email, on 6/22/23 at 12:19 PM with Employee Identifier (EI) # 1, Administrator, who confirmed there was no documentation of a comprehensive pain assessment for the above times on 6/6/23 and 6/7/23. EI # 1 further confirmed the hospital does not have a policy and/or procedure for pain assessment, reassessment, and adjustment of the pain plan.

2. PI # 23 was admitted to the hospital on 6/29/23 with diagnoses including Electrical Burn.

Review of the Physician orders dated 6/29/23 revealed an order to check fingerstick blood glucose prior to meals and at bedtime.

Review of the Blood Sugar and Insulin Flow Sheet dated 6/29/23 revealed no documentation a blood glucose fingerstick was obtained prior to supper.

An interview was conducted on 7/7/23 at 12:14 PM with EI # 2, Director of Nursing, who confirmed there was no documentation of a supper blood glucose fingerstick on 6/29/23 per the physician's orders.

3. PI # 24 was admitted to the hospital on 6/26/23 with diagnoses including Type 2 Diabetes Mellitus Uncontrolled and Hyperglycemia.

Review of the Physician orders dated 6/26/23 revealed an order to check fingerstick blood glucose and administer sliding scale insulin prior to meals and at bedtime.

Further review of the Physician orders dated 6/26/23 revealed a blood sugar of 151 to 200 Milligrams per deciliter (mg/dL), 4 Units of Novolog or Humalog Insulin was to be administered subcutaneous (SQ) and for a blood sugar of 201 to 250 mg/dL, 8 Units of Novolog or Humalog Insulin was to be administered SQ.

Review of the Blood Sugar and Insulin Flow Sheet dated 6/27/23 at 9:00 PM revealed a blood glucose fingerstick of 219 was obtained. There was no documentation the sliding scale insulin was administered.

Review of the Blood Sugar and Insulin Flow Sheet dated 6/28/23 at 6:30 AM revealed a blood glucose fingerstick of 161 was obtained. There was no documentation the sliding scale insulin was administered.

An interview was conducted on 7/7/23 at 12:05 PM with EI # 2, who confirmed there was no documentation the sliding scale insulin was administered per the physician order on 6/27/23 at 9:00 PM and 6/28/23 at 6:30 AM.

4. PI # 21 was admitted to the hospital on 6/14/23 with diagnoses including Dyspnea, Hypertensive Disorder, Chronic Obstructive Lung Disease.

Review of the Physician orders dated 6/15/23 revealed an order for Tylenol Extra Strength 2 tablets orally now.

Review of the nursing notes dated 6/15/23 revealed:

At 12:05 AM, the nurse documented the patient complained of pain in legs. There was no documentation of the pain intensity, quality, aggravating and alleviating factors.

At 5:30 AM, the nurse documented the patient requested Tylenol. There was no documentation of the location of the pain, pain intensity, quality, aggravating and alleviating factors.

Review of the MR revealed no documentation a pain plan for the patient had been developed.

An interview was conducted on 7/7/23 at 12:09 PM with EI # 2, who confirmed there was no documentation of a pain plan and comprehensive pain assessment for the above times on 6/15/23.

5. PI # 26 was admitted to the hospital on 4/28/23 with diagnoses including Dehydration, Anterior Chest Wall Pain, Rhabdomyolysis, and Chest Pain.

Review of the Physician orders dated 4/29/23 revealed an order for Tylenol 650 mg (milligrams) every 4 to 6 hours as needed for pain.
Review of the nursing notes dated 4/29/23 revealed:

At 1:20 AM, the nurse documented the patient complained of on and off chest pain. There was no documentation of the pain intensity, quality, aggravating and alleviating factors.

At 1:21 AM, the nurse documented the patient was administered Tylenol 650 milligrams (mg). There was no documentation of a reassessment of the pain following Tylenol administration.

At 10:20 AM, the nurse documented the patient verbalized chest pain when walking around and the nurse administered Tylenol 650 mg. There was no documentation of the pain intensity, quality, alleviating factors and a reassessment of the pain following Tylenol administration.

An interview was conducted on 7/7/23 at 11:59 PM with EI # 2, who confirmed there was no documentation of a comprehensive pain assessment and reassessment for the above times on 4/29/23.

6. PI # 28 was admitted to the hospital on 3/28/23 with diagnoses including Sickle Cell-Hemoglobin SS (abnormal genotypes or the sickle cells) Disease, Hemoglobin SS disease with crisis and Hypertensive Disorder.

Review of the Physician orders dated 3/28/23 revealed an order for Dilaudid 1 mg intravenously (IV) every 6 hours as needed for pain.

Review of the nursing notes dated 3/28/23 revealed at 5:00 AM and 11:05 AM, the nurse documented the patient complained of abdominal pain and was administered Dilaudid 1 mg IV. There was no documentation of the pain intensity, quality, aggravating, alleviating factors and a reassessment of the pain following Dilaudid administration.

An interview was conducted on 7/7/23 at 12:03 PM with EI # 2, who confirmed there was no documentation of a comprehensive pain assessment and reassessment for the above times on 3/28/23.



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7. PI # 27 was admitted on 5/12/23 with diagnoses including Metabolic Acidosis, Uremia, and Chronic Kidney Disease.

Review of the admission orders dated 5/12/23 revealed orders for Dilaudid 0.5 mg to 1 mg IV every four hours for pain with Benadryl 25 mg IV.

Review of the Medication/IV Solution Charge Sheet dated 5/13/23 revealed the nurse documented on the 12:00 AM row, Dilaudid 1 mg and Benadryl 25 mg.

Review of the Nursing Notes dated 5/12/23 and 5/13/23 revealed no documentation of the specific time the medication was given, the location of pain, or pain intensity.

Further review of the Nursing Notes dated 5/12/23 and 5/13/23 revealed the nurse documented "...pt (patient) has a dressing to the left mid-abdomen covering small wound with Xeroform, dressing reinforced with new Xeroform, pad, and paper tape..."

There was no documentation of the wound assessment including drainage and measurements.

Review of the physician orders dated 5/12/23 and 5/13/23 revealed no documentation of wound care orders.

A copy of a policy for wound care was requested on 7/6/23, none was provided.

An interview was conducted on 7/7/23 at 11:54 AM with EI # 1 who confirmed the staff failed failed to document the medication administration time and pain location and intensity and failed to include an assessment of the wound measurements and drainage.

Based on review of medical records (MR), hospital policy and procedure and interviews with the staff it was determined the hospital failed to ensure a care plan was developed and updated for each patient admitted to the hospital.

This affected 6 of 21 inpatient MR's reviewed and did affect Patient Identifier (PI) # 13, PI # 18, PI # 23, PI # 31, PI # 24, PI # 21 and had the potential to negatively affect all patients admitted to the hospital.

Findings include:

Hospital Policy: Comprehensive Care Plan.
Policy Number: None.
Policy Date: 5/30/18.

Purpose:

Purpose and intent is to develop a comprehensive plan of care for each patient that incorporates assessment data, goals, interventions, rationales and outcome evaluations.

Protocol:

1. Initiate as soon as possible after admission for each patient.
2. Describe patient goals as well as address appropriate discharge planning.
3. Develop appropriate nursing interventions in response to nursing care needs.
4. Plan needs to be consistent with attending doctor's plan of medical care.
5. Must be kept current and revised as the needs are assessed and responses to interventions of the patient change.
6. The nursing care plan is part of the official medical record.

1. PI # 13 was admitted to the facility on 7/29/22 with diagnoses including Cellulitis of Lower Limb and Infection Due to Resistant Bacteria.

Review of the MR revealed no documentation a care plan was developed on admission and updated as needed with changes in the patient's condition.

An interview was conducted on 6/22/23 at 12:35 PM by email with Employee Identifier (EI) # 1, Administrator, who confirmed the staff failed to complete a care plan on PI # 13.



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2. PI # 18 was admitted to the hospital on 6/5/23 with diagnoses including Syncopal Episode.

Review of the MR revealed no documentation a care plan was developed on admission and updated as needed with changes in the patient's condition.

An interview was conducted, via email, on 6/22/23 at 12:19 PM with EI # 1 who confirmed the staff failed to complete a care plan on PI # 18.

3. PI # 23 was admitted to the hospital on 6/29/23 with diagnoses including Electrical Burn.

Review of the MR revealed no documentation a care plan was developed on admission and updated as needed with changes in the patient's condition.

An interview was conducted on 7/7/23 at 12:14 PM with EI # 2, Director of Nursing, who confirmed the staff failed to complete a care plan on PI # 23.

4. PI # 31 was admitted to the hospital on 5/16/23 with diagnoses including Type 2 Diabetes Mellitus, Atrial Fibrillation with Rapid Ventricular Response and Hypertensive Disorder.

Review of the Care Plan dated 5/20/23, two days after discharge of the patient on 5/18/23, revealed documentation of "Deficient diversional activity: reduced stimulation, interest, or participation in recreational or leisure activities."

Further review of the Care Plan dated 5/20/23 revealed no documentation of interventions and goals related to Type 2 Diabetes Mellitus, Atrial Fibrillation with Rapid Ventricular Response and Hypertensive Disorder.

An interview was conducted on 7/7/23 at 12:17 PM with EI # 2, who confirmed there was no documentation of interventions and goals related to Type 2 Diabetes Mellitus, Atrial Fibrillation with Rapid Ventricular Response and Hypertensive Disorder and the care plan was created after the patient was discharged.

5. PI # 24 was admitted to the hospital on 6/26/23 with diagnoses including Type 2 Diabetes Mellitus Uncontrolled and Hyperglycemia.

Review of the Care Plan dated 6/26/23 revealed documentation of "Ineffective health maintenance: Inability to identify, manage, and/or seek help to maintain health."

Further review of the Care Plan dated 6/26/23 revealed no documentation of interventions and goals related to Type 2 Diabetes Mellitus and Hypertensive Disorder.

An interview was conducted on 7/7/23 at 12:05 PM with EI # 2, who confirmed there was no documentation of interventions and goals related to Type 2 Diabetes Mellitus and Hypertensive Disorder.

6. PI # 21 was admitted to the hospital on 6/14/23 with diagnoses including Dyspnea, Hypertensive Disorder, Chronic Obstructive Lung Disease.

Review of the MR revealed no documentation a care plan was developed on admission and updated as needed with changes in the patient's condition.

An interview was conducted on 7/7/23 at 12:09 PM with EI # 2, who confirmed the staff failed to complete a care plan on PI # 21.

Based on observations, hospital policy and procedure, and interviews it was determined the hospital failed to ensure all out of date drugs and biologicals were not available for patient use.

This deficient practice had the potential to affect all patients receiving medications at this hospital.

Findings include:

Hospital policy: Expiration Dates
Policy number: 09-02
Reviewed Date: 10/19/10

Policy: Expired drugs and devices shall not be made available for patient use...

Procedure:
Expiration date interpretation: If an expiration date is expressed only as a month and year, the date of expiration shall be the conclusion of the last day of the stated month.

...Expiration date monitoring:

...Expiration dates of drugs and devices shall be checked during the routine medication area inspections and all drugs and devices scheduled to expire during the next month shall be removed from stock.

1. A tour of the pharmacy department was conducted on 6/13/23 at 2:45 PM with Employee Identifier (EI) # 2, Director of Nursing.

Cefazolin one gram for injection, sixty-six vials, expiration date May 2023, were on the shelf for patient use.

Polyethylene Glycol-3350 powder packs, seventy-nine individual packets with expiration date of May 2023 were on the shelf for patient use.

An interview was conducted on 6/13/23 at 3:00 PM with EI # 2 who confirmed the medications were out of date and were available for patient use.

Based on observations, review of hospital policy and procedure, and interviews with staff, it was determined the hospital failed to ensure:

1. Safe storage of food items in the dietary department.

2. Foods were labeled with the opened date and discard or expired date.

3. Expired foods were not available for use.

4. Prepared foods were labeled with the date prepared, discard date and discarded when expired.

5. Sanitizing solutions were mixed appropriately, tested for proper concentration of chlorine and results documented.

6. Freezer temperatures were monitored.

This had the potential to affect all patients admitted to this hospital.

Findings include:

Hospital policy: Dietary.
Policy number: none provided.
Revised Date: 1/14/21.

Policy:

1. Storage procedure for left-over cooked foods.

2. Storage of open uncooked food...

Procedure: ...Place foods in proper containers, closed tightly. Label, date and initial all containers...

Items not used within 72 hours will be discarded.

Uncooked refrigerated canned foods not used within 72 hours will be discarded...

A tour of the Dietary department was conducted on 6/13/23 at 9:00 AM with Employee Identifier (EI) # 3, Dietary Manager, and EI # 4, Dietary staff, the following deficiencies were observed:

1. Observation of the three-door refrigerator revealed the following items:

a. A covered dish with the label tomato soup dated 5/16/23, 28 days since labeled.
b. A covered dish with the label baked beans dated 6/2/23, 11 days since labeled.
c. A covered dish with the label spaghetti sauce dated 5/18/23, 26 days since labeled.
d. A covered bowl with the label sweet peas dated 6/6/23, seven days since labeled.
e. A covered container labeled tuna salad, no date on the label.
f. Twenty-seven Styrofoam cups filled with tea. There was no date on cups when prepared.

2. Observation of the plate warmer revealed a prepared patient tray in a Styrofoam container. There was no label indicating the date when the plate was prepared.

3. Under the prep table a one-gallon plastic container labeled oatmeal and a one-gallon plastic container labeled grits were observed. The containers were not the original containers and there was no date when they were filled.

4. Observation of the three-compartment sink revealed sink number one was filled with wash solution. EI # 4 stated he/she adds about one half cup of Clorox each time he/she fills the sink. EI # 4 stated he/she does not check the concentration of bleach.

5. Observation of the chest freezer revealed no thermometer.

6. Observation of the upright freezer revealed a thermometer that was frozen to the shelf and iced over. The thermometer dial was not covered with glass and was not working. EI # 3 stated they do not monitor or keep a log of the freezer temperatures.

7. Observation of the dry food storage area revealed two one-gallon zip lock bags filled with elbow noodles. There was no label with the date when the bags were to be discarded.

An interview was conducted on 6/13/23 at 10:30 AM with EI # 3, who confirmed the department failed to ensure all foods were labels with a discard date, the bleach concentration in the sink was checked, and the freezer temperatures were monitored.

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

Findings include:


Refer to Life Safety Code violations and A- 724 for findings.

Based on observations, review of hospital policy, and interviews, it was determined the staff failed to ensure:

1. Supplies available for patient use were not expired.

2. Monthly checklist and/or inspection was completed and documented for expired supplies per the hospital policy.

This had the potential to negatively affect all patients receiving care at this hospital.

Findings include:

Hospital Policy: Drugs and Supplies Storage/Expiration.
Policy Number: Not documented.
Effective Date: 5/30/18.

Drugs and Supplies Storage/Expiration.

Expiration Date Monitoring.

...2. Expiration dates of medications, supplies ...shall be checked monthly and during routine medication inspections and all medications, supplies ...scheduled to expire during the next month shall be remove form stock.

3. Monthly check list is to be completed and maintained to monitor compliance.

...Expiration dates on non-pharmacy supplies.

...2. When an expired supply is discovered, it will be removed or replaced...

1. A tour of the Emergency Department (ED) was conducted on 6/13/23 at 1:00 PM with Employee Identifier (EI) # 1, Administrator. The following supplies were observed in the ED, available for patient use and expired and/or opened:

a. Open Disposable Sterile Bone Marrow Biopsy/Aspiration Needle.
b. Two open sterile 4 by 4 gauze.
c. Open sterile suture removal kit.
d. Three Xeroform petrolatum dressings. Two of the dressings expired on 1/23 and one on 5/2020.
e. Three opened Hydrogen Peroxide 3 % bottle 473 ml (milliliter) without an opened date documented.
f. Three Adaptec non-adhering dressing which expired on 5/2020.
g. Yankauer suction instrument which expired on 12/19.
h. Opened tegaderm film which expired on 4/15/23.
i. Opened sterile water for irrigation 1000 ml without an opened date documented.
j. Huber needle and wing 20 Gauge (G) ¾ inch (") which expired on 11/2020.
k. Two port access infusion sets which expired on 9/30/21.
l. Opened Buretrol (brand) solution set.
m. Four chest tube trays which expired on 7/31/22.
n. Chest tube kit which expired on 1/31/21.
o. Opened sterile laceration tray.
p. Two Endotracheal tube introducers. One expired on 1/30/23 and one on 1/4/23.
q. Four adult colorimetric CO 2 (Carbon dioxide) detectors. Two expired on 1/11/23 and two on 5/11/23.
r. Jackson-Pratt drain which expired on 1/19.
s. Three silicone round drains 19 FR (French). One expired on 3/19, one on 9/30/19, and one on 10/31/19.
t. Two silicone flat drains 10 mm (millimeter). One expired on 9/30/19 and one on 11/30/19.
u. Silicone round drain 24 FR which expired on 8/19.
v. Silicone flat fluted drain 10 mm which expired on 5/19.
w. Jackson-Pratt reservoir which expired on 9/30/19.
x. Jackson-Pratt reservoir kit with a silicone flat drain which expired on 8/31/19.

EI # 1 confirmed, during the tour, expired and opened supplies being available for patient use was against the hospital policy.

An interview was conducted, via email, on 6/23/23 at 9:00 AM with EI # 1, who confirmed there was no documentation of a monthly check list and/or inspection for expired supplies per hospital policy.



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2. A tour of the Medical Unit was conducted on 6/13/23 at 2:30 PM with EI # 2, Director of Nursing. During the tour, the crash cart at the nurse's station on the Medical Unit was inspected.

The follow supplies were observed and expired:

Twelve 10 ml Luer Lock Tip syringes which expired on 10/31/22.
A 20 ml syringe which expired on 12/20/22.

An interview was conducted with EI # 2 on 6/13/23 at 2:45 PM who confirmed the supplies found in the crash cart were expired.

Based on staff interviews, hospital policy and procedure, Center for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings, and review of personnel files it was determined the hospital failed to:

1. Appoint an individual who had the training to lead the Infection Control (IC) program and antibiotic stewardship program.

2. Ensure hospital staff performed hand hygiene according to hospital policy.

3. Observe, evaluate and analyze infection control practices at the hospital.

4. Compute infection attack rates per policy.

5. Report to the Infection Control Committee the percentage of admitted infections and all nosocomial infections per policy.

6. Provide a yearly surveillance report to the Infection Control Committee per policy.

7. Establish a hospital policy for an antibiotic stewarship program.

8. Coordinate among all components of the hospital responsible for antibiotic use and resistance including the hospital IC Program.

9. Document the evidence-based use of antibiotics in all departments and services of the hospital.

10. Document improvements, including sustained improvements, in proper antibiotic use.

11. Document adherence to nationally recognized guidelines, as well as best practices, for improving antibiotic use.

12. Reflect the scope and complexity of the hospital services provided in the antibiotic stewardship program.

13. Document all infectious diseases identified by the infection prevention and control program as well as antibiotic use issues identified by the antibiotic stewardship program, and are addressed in collaboration with hospital QAPI (Quality Assurance and Performance Improvement)leadership.

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

Findings include:

Refer to A 748, A 749, A 750, A 760, A 761, A 762, A 763, A 764, A 765, and A 771 for findings.

Based on staff interviews and review of personnel files it was determined the hospital failed to appoint an individual who had the training to lead the Infection Control (IC) program.

This had the potential to affect all patients admitted to this hospital.

Findings include:

1. Review of the hospital IC program was conducted on 7/7/23 at 9:16 AM with Employee Identifier (EI) # 2, Director of Nursing (DON). During the review, EI # 2 verbalized EI # 9, Assistant DON, was the leader of the hospital IC program.

A review of the personnel file for EI # 9 revealed no documentation of education, training, experience, or certification in infection prevention and control.

Further review of the personnel file for EI # 9 revealed no documentation EI # 9 was appointed by the governing body as the infection Preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and the appointment was based on the recommendations of medical staff leadership and nursing leadership.

An interview was conducted on 7/7/23 at 1:00 PM with EI # 1, Administrator, who confirmed there was no documentation EI # 9 was provided education, training, experience, or certification in infection prevention and control, was appointed by the governing body as the infection Preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and the appointment was based on the recommendations of medical staff leadership and nursing leadership.

Based on observations, hospital policy and procedure, Center for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings, CDC Best Practices for Environmental Cleaning in Healthcare Facilities and interviews, it was determined the staff failed to ensure:

1. Hand hygiene was performed according to hospital policy.

2. Reuseable blood pressure cuff was cleaned during a terminal room cleaning.

This deficient practice had the potential to negatively affect all patients admitted to the hospital.

Findings include:

Hospital Policy: Hand Hygiene.
Policy Number: Not documented.
Effective Date: Not documented.

Policy: It is the policy of J. Paul Jones Hospital to minimize risk factors for transmission of infectious organisms from the hands of health care providers ...

Procedures: Hand hygiene should occur in the following situations:

...After removing gloves.

CDC Hand Hygiene in Healthcare Settings.
Reviewed Date: 1/30/2020.

...Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications:
Immediately before touching a patient.
...Immediately after glove removal.

CDC Best Practices for Environmental Cleaning in Healthcare Facilities.
Reviewed Date: 4/21/2020.

...4. Environmental Cleaning Procedures.

...Common high-touch surfaces include:

...patient monitoring equipment...

4.6.5 Emergency Departments.

...recommended frequency and process for Emergency Departments.

...Examination (rooms)...after each event/case...process...high-touch surfaces...

1. An observation was conducted on 6/14/23 at 12:51 PM with Employee Identifier (EI) # 8, Registered Nurse and EI # 2, Director of Nursing, to observe Intravenous (IV) placement.

During the observation, EI # 8 and EI # 2 both donned gloves twice to provide patient care without performing hand hygiene. EI # 8 failed to perform hand hygiene once after the removal of gloves.

An interview was conducted on 7/7/23 at 9:30 AM with EI # 2, who confirmed she/he and EI # 8 failed to follow the hospital policy and CDC guidelines for hand hygiene.



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2. A observation of a Emergency Department patient room terminal cleaning was conducted on 6/14/23 at 12:00 PM with EI # 6, Housekeeper.

EI # 6 used Everwipe disinfecting wipes to clean the patient contact areas in the room but failed to clean and disinfect the blood pressure cuff.

An interview was conducted on 7/7/23 at 11:54 AM with EI # 1, Administrator, who confirmed the staff failed to ensure all patient contact areas were disinfected after patient discharge.

Based on observations of care from 6/13/23 to 7/7/23, review of the hospital Infection Control (IC) program and hospital policy the hospital failed to:

1. Observe, evaluate and analyze infection control practices at the hospital.

2. Compute infection attack rates per policy.

3. Report to the Infection Control Committee the percentage of admitted infections and all nosocomial infections per policy.

4. Provide a yearly surveillance report to the Infection Control Committee per policy.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

Hospital Policy: Infection Control Committee Surveillance Program
Policy Number: Not documented
Effective Date: 1/1/87

Purpose: To detect and record infections and to institute effective control measures.

...4. Use of collected data.

...b. Compute infection attack rates.
...d. Report to the Infection Control Committee percentage of admitted infections and all nosocomial infections.

5. Reporting.
a. Yearly surveillance report to Infection Control Committee.

1. Review of the hospital IC program was conducted on 7/7/23 at 9:16 AM with Employee Identifier (EI) # 2, Director of Nursing. The surveyor asked for the hospital IC staff observation documentation. EI # 2 verbalized the hospital has not performed IC staff observations in years.

Review of the IC Antibiotics Surveillance Report for February 23 to June 23 revealed documentation of patient infections in the hospital. Further review revealed no documentation if each patient infection was nosocomial (hospital acquired), or community acquired.

Further review of the hospital IC program revealed no documentation the infection attack rates were computed, a report with the percentage of admitted infections and all nosocomial infections and a yearly surveillance report.

EI # 2 confirmed, during the hospital IC program review on 7/7/23 at 9:16 AM, there was no documentation the infection attack rates were computed, the percentage of admitted infections and all nosocomial infections were reported or a yearly IC surveillance report was submitted.

Based on staff interviews and review of personnel files it was determined the hospital failed to establish a policy for an antibiotic stewardship program and appoint an individual who had the training to lead the program.

This had the potential to affect all patients admitted to this hospital.

Findings include:

1. The surveyor requested the hospital policy for the Antibiotic Stewardship program. No policy was provided.

The surveyor asked who had been appointed as leader of the program. Employee Identifier (EI) # 1, Administrator, stated EI # 9, Assistant Director of Nursing, was over the program.

A review of the personnel file for EI # 9 revealed no documentation of training for antibiotic stewardship.

An interview was conducted on 7/7/23 at 1:00 PM with EI # 1, who confirmed there was no documentation EI # 9 had received training for antibiotic stewardship or had been appointed by the Governing Body.

Based on review of the hospital Infection Control (IC) Program and staff interviews the hospital failed to demonstrate coordination among all components of the hospital responsible for antibiotic use and resistance including the hospital IC Program.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

1. Review of the hospital IC program was conducted on 7/7/23 at 9:16 AM with Employee Identifier (EI) # 2, Director of Nursing. Review of the hospital IC Program revealed no documentation of the hospital Antimicrobial Stewardship Program, including antibiotic use and resistance.

During the review of the hospital IC program, EI # 2, stated "...We don't have an antibiotic stewardship program."

An interview was conducted on 7/7/23 at 9:30 AM with EI # 5, Pharmacist, who verbalized he/she did not participate in a antibiotic stewardship program at the hospital.

Based on review of the hospital Infection Control (IC) Program and staff interviews the hospital failed to document the evidence-based use of antibiotics in all departments and services of the hospital.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

1. Review of the hospital IC program was conducted on 7/7/23 at 9:16 AM with Employee Identifier (EI) # 2, Director of Nursing. Review of the hospital IC Program revealed no documentation of the hosptial Antimicrobial Stewardship Program, including evidence-based use of antibiotics in all departments and services of the hospital.

During the review of the hospital IC program, EI # 2, stated "...We don't have an antibiotic stewardship program."

An interview was conducted on 7/7/23 at 9:30 AM with EI # 5, Pharmacist, who verbalized he/she did not participate in a antibiotic stewardship program at the hospital.

Based on review of the hospital Infection Control (IC) Program and staff interviews the hospital failed to document improvements, including sustained improvements, in proper antibiotic use.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

1. Review of the hospital IC program was conducted on 7/7/23 at 9:16 AM with Employee Identifier (EI) # 2, Director of Nursing. Review of the hospital IC Program revealed no documentation of the hospital Antimicrobial Stewardship Program, including proper antibiotic use with documented and sustained improvements.

During the review of the hospital IC program, EI # 2, stated "...We don't have an antibiotic stewardship program."

An interview was conducted on 7/7/23 at 9:30 AM with EI # 5, Pharmacist, who verbalized he/she did not participate in a antibiotic stewardship program at the hospital.

Based on review of the hospital Infection Control (IC) Program and staff interviews the hospital failed to document adherence to nationally recognized guidelines, as well as best practices, for improving antibiotic use.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

1. Review of the hospital IC program was conducted on 7/7/23 at 9:16 AM with Employee Identifier (EI) # 2, Director of Nursing. Review of the hospital IC Program revealed no documentation of the hospital Antimicrobial Stewardship Program, including documented adherence to nationally recognized guidelines and best practices for improving antibiotic use.

During the review of the hospital IC program, EI # 2, stated "...We don't have an antibiotic stewardship program."

An interview was conducted on 7/7/23 at 9:30 AM with EI # 5, Pharmacist, who verbalized he/she did not participate in a antibiotic stewardship program at the hospital.

Based on review of the hospital Infection Control (IC) Program and staff interviews the hospital failed to reflect the scope and complexity of the hospital services provided.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

1. Review of the hospital IC program was conducted on 7/7/23 at 9:16 AM with Employee Identifier (EI) # 2, Director of Nursing. Review of the hospital IC Program revealed no documentation of the hospital Antimicrobial Stewardship Program to include the proper use of antimicrobials.

During the review of the hospital IC program, EI # 2, stated "...We don't have an antibiotic stewardship program."

An interview was conducted on 7/7/23 at 9:30 AM with EI # 5, Pharmacist, who verbalized he/she did not participate in a antibiotic stewardship program at the hospital.

Based on review of the hospital Infection Control (IC) Program and staff interviews the hospital failed to document all infectious diseases identified by the infection prevention and control program as well as antibiotic use issues identified by the antibiotic stewardship program are addressed in collaboration with hospital QAPI (Quality Assurance and Performance Improvement)leadership.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

1. Review of the hospital QAPI program was conducted on 7/7/23 at 9:46 AM with Employee Identifier (EI) # 2, Director of Nursing. Review of the hospital QAPI Program revealed no documentation of the hospital Infection prevention and control program.

During the review of the hospital QAPI program, EI # 2, stated "...We don't have an antibiotic stewardship program" and confirmed there was no documentation of the hospital Infection prevention and control program in the hospital QAPI Program.

Based on MR (medical record) reviews and staff interviews it was determined the hospital failed to ensure the staff transmitted the patient's necessary medical information in one of one inpatient MRs reviewed with a home health referral, including Patient Identifier (PI) # 21.

This deficient practice had the potential to negatively affect all patients referred for home health.

1. PI # 21 was admitted to the hospital on 6/14/23 with diagnoses including Dyspnea, Hypertensive Disorder, Chronic Obstructive Lung Disease.

Review of the Physician's Orders dated 6/16/23 revealed an order to refer the patient to home health.

Review of the MR revealed no documentation the patient's medical information was transmitted to a home health agency.

An interview was conducted on 7/7/23 at 12:09 PM with Employee Identifier # 2, Director of Nursing, who confirmed there was no documentation the patient's medical information was transmitted to a home health agency.

Based on MR (medical record) reviews and staff interviews it was determined the hospital failed to ensure the staff provided the patient a list of available home health agencies in one of one inpatient MRs reviewed with a home health referral, including Patient Identifier (PI) # 21.

This deficient practice had the potential to negatively affect all patients referred for home health.

1. PI # 21 was admitted to the hospital on 6/14/23 with diagnoses including Dyspnea, Hypertensive Disorder, Chronic Obstructive Lung Disease.

Review of the Physician's Orders dated 6/16/23 revealed an order to refer the patient to home health.

Review of the MR revealed no documentation the patient was provided a list of available home health agencies which served the area.

An interview was conducted on 7/7/23 at 12:09 PM with Employee Identifier # 2, Director of Nursing, who confirmed there was no documentation the patient was provided a list of available home health agencies which served the area.