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Based on Safety Manual and Generator Log Book review, observation, and interview, it was determined the facility did not meet Life Safety Code requirements related fire damper testing, monthly load exercise of the generator, and maintenance of penetrations of smoke barriers and corridor walls to resist the passage of fire and smoke. The failed practices had the potential to affect all patients, staff, and visitors. The facility had a census of 14 patients on 10/28/14. See K-17, K-25, K-104, and K-144.

Based on Safety Manual review and interview, it was determined that the facility did not ensure inspections were done by the local fire department once a year as required by policy. The failed practice had the potential to affect the health and safety of all patients, staff and visitors because the fire department familiarity of the potential hazards and physical layout of the facility was not assured. The facility had a census of 14 patients on 10/28/14.

A. In an interview on 10/28/14 at 1530, the Maintenance Director verified there was no documentation of fire department inspection available for review.
B. Review of the Safety Manual on 10/29/14 at 1400 revealed Policy #1117 required "at least once a year the Public Fire Department will make an inspection to orient their fighters to the facility and to coordinate plans with the Piggott Community Hospital Safety Committee."

Based on physician credential file review and interview, it was determined the facility failed to ensure six (#3-#7, and #9) of nine (#1-#9) physician credential files contained professional references as stated in the Medical Staff Bylaws. Failure to provide professional references did not allow the facility to be aware of the Physicians' characteristics in a professional environment and could affect any patient admitted to the facility. Findings follow.

A. Review of the Medical Staff Bylaws regarding applications for Medical Staff membership stated "favorable recommendations from references and other hospitals/individuals regarding professional/ethical character."
B. Review of physician credential files revealed there was no references for Physician #3-#7 and #9.
C. During an interview on 10/29/14 at 1230, the Administrative Assistant confirmed the credential files did not have references for Physician #3-#7 and #9.

Based on review of policies and procedures and interview, it was determined the facility failed to assure the Emergency Department Policy and Procedure Manual reflected current practice and processes. It could not be assured patients would receive care consistent with current facility practices. The failed practice was likely to affect any patient who presented to the emergency department for treatment. The findings were:

A. Review of the Emergency Department Policy and Procedure Manual, Volume I and II on 10/29/14 revealed the signature page noted that "This Policy and Procedure manual was reviewed and approved at the medical staff meeting on 10/07/14." Another statement "This policy and procedure manual was reviewed and approved at the governing board meeting on 10/13/14." The page was signed by the Medical Director, Director of Clinical Services, Chief of Staff and Governing Board Chairman.
B. The Emergency Department Policy and Procedure Manual included the following examples of policies that were no longer current to facility practices or were outdated:
1) "678.126 Mental or Violent Patients" which included the statement "Information that may be given to press when Oked by doctor: name, age, address, occupation, employer, etc..; shooting - confirm wound exists and where; stabbing - same; fracture - member involved and if simple or compound; head injury - confirm there is injury; internal injuries - confirm they exist and may be serious; unconsciousness - that patient is or was unconscious; poisoning - nothing, intoxication - nothing; burns - part of body involved (how occurred only if definitely known.); doctor attending - only with doctor's consent; photograph only - must have parent's or patient's written consent."
2) "678.47A Use of ER for Outpatient Surgery" which included the statement "The Observation Bed area will primarily serve as the pre and post-op observation room for outpatient surgery" and "family member will be involved in the care of the patient. They will be asked to wait in the ER (Emergency Room) Waiting room while the patient is being prepared for surgery and during surgery" and "outpatient surgery patients will initially be recovered in the recovery room and moved to ER or area designated as observation area only after stable and vital signs are ready to be monitored every 15 minutes until completely stable."
3) "678.64 Coroner's Cases" which included the statement "Ark. Stat. Ann. 42-1212 specifies that when a person dies under the following circumstances or as a result of the following causes, these deaths shall be reported to the county coroner, by the RN in charge at the time of presentation."
C. The Director of Nursing and Nurse Manager of the ER were interviewed on 10/29/14 at 1355 at which time they confirmed the ER Policy and Procedure Manual included policies that did not reflect current facility practices such as the policy examples at B1-3.

Based on observation and interview, it was determined the facility failed to identify potential sources of infection in the Emergency Department (ED) in that manufacturer's instructions for cleaning the ear wash system was not followed and failed to assure chairs used in the triage room, ED #3 and ED#4 were without rips and tears in vinyl covering. Failure to clean and sanitize equipment and furnishings did not assure infection would be prevented. The failed practice would likely affect any patient treated in the emergency department. The findings were:

A. Observation on tour 10/28/14 at 1335 revealed a Welch Allyn Ear Wash system in the cabinet in ED #3. There were two sets of clear tubing for use with the ear wash unit. Both sets of tubing had standing water in the tubing and one set had areas of discoloration inside the clear tubing.
B. The ED Manager was asked how the system and tubing were cleaned. The ED Manager stated in an interview on 10/28/14 that the tips were changed and the outside wiped with disinfectant wipes. Surveyor #1 requested Manufacturer's instructions for use and cleaning of the ear wash system. The Emergency Department Manager provided a copy on 10/28/14 at 1335. The following information was noted with the ear wash system instructions:
1) "To clean the unit, prepare a 4-cup solution of soap and water."
2) "Detach the chamber from the faucet. Leave the hoses attached to the unit and pour ½ cup of the solution into the top opening of the coupler."
3) "Replace the chamber on the faucet head and submerge the exposed handle interface surfaces into the remainder of the solution."
4) "Turn on the water. Squeeze the actuator to allow the solution to flow from the handle into the container. The suction line will remove the solution. Continue this process for 5 minutes."
5) "Turn the water off and remove both tubes from the chamber."
6) "To remove any stagnant solution in the tubing, disconnect the hoses from the chamber and place the open end in the sink. Hold the handle higher than the tube and squeeze the actuator. The water will run out of the open end and into the sink basin."
7) "Remove the chamber form the faucet. Allow the chamber to drip dry. Replace the unit in its holder."
C. Observation on tour 10/28/14 at 1335 revealed chairs in the Triage Room, ED #3 and ED #4 were covered in a black vinyl type material. Each of the chairs had rips in the vinyl exposing the padding material beneath and the chairs cannot be sanitized.
D. The Emergency Department Manager confirmed the findings at A, B and C at the time of the observation.

Based on observation, clinical record, policy and procedure review and interview, it was determined three (#1-#3) of five physicians failed to complete the clinical record timely which was defined as 30 days for 172 clinical records. Failure to have a complete clinical record did not assure continuity of patient care. The failed practice was likely to affect all patients in the facility. The findings were:

A. Observation of the Health Information Management (HIM) Department revealed multiple clinical records on shelves and organized by physician name. The HIM Director identified the clinical records as incomplete and confirmed three physicians with privileges had clinical records that were incomplete over 30 days: 118 clinical records for Physician #1; 48 clinical records for Physician #2, and 6 clinical records for Physician #3.
B. Review of the policy and procedure "Completion of the Medical Record" as provided by the HIM Director revealed "Each physician is responsible for the timely completion of the charts of the patients under his care."
C. The HIM Director stated in an interview 10/31/14 at 1030 that the facility "requires all signatures and dictation be completed within 30 days of discharge." At the time of the interview the HIM director confirmed a monthly report of clinical records incomplete after 30 days was reported by physician name to Utilization Review and this was reported up through the Medical Staff and Governing Body.
D. On 10/31/14 at 1035, the Administrator was interviewed and stated he was aware of the delinquent clinical records and had "addressed the issue with the physicians on numerous occasions."

Based on clinical record review, policy review and interview, it was determined the facility failed to assure a comprehensive care plan was developed for three of three (#1-#3) swing-bed clinical records reviewed. The failed practice did not assure services would be provided to attain the patients highest level of functioning. The failed practice affected Patient #1 - #3 and would likely affect all patient's admitted to swing-bed status. The findings were:

A. On 10/30/14 clinical record review was conducted with the Swing-bed Coordinator. Patient #1 was admitted to the swing-bed on 10/13/14 at 1450. Documentation from 10/14/14 - 10/28/14 revealed a Stage II wound to the coccyx. Review of the Patient Care Plan, initiated on 10/13/14 and last reviewed on 10/29/14 revealed no problem, need, or intervention related to the Stage II wound to the coccyx. The Swing-bed Coordinator confirmed on 10/30/14 at 1445 the Patient Care Plan did not address the Stage II wound to the coccyx.
B. Patient #2 was admitted to the swing-bed on 10/20/14 at 1610. Physician Orders form (as written by Advance Practice Nurse) was reviewed and on 10/21/14 at 1515 revealed "Do not leave walker in room. Patient must not get up by herself and notify patient with each encounter." Review of the Patient Care Plan revealed "Weakness fall risk" dated 10/20/14. The Patient Care Plan did not include fall risk interventions as listed on the Physician Orders form. The Swing-bed Coordinator confirmed on 10/30/14 at 1530 the Patient Care Plan did not include all fall risk interventions for Patient #2.
C. Patient #3 was admitted on 10/17/14 at 1630. Review of the admission physician orders revealed Fentanyl patch 25 mcg (micrograms) topically every 72 hours for pain and Morphine 3 mg (milligrams)intravenously prn (as necessary) every 2 hours for pain." A re-order of the medication was noted 10/24/14. Review of the Patient Care Plan revealed pain was not addressed. The Swing-bed Coordinator confirmed on 10/30/14 at 1600 that Patient #3's pain was not addressed on the Patient Care Plan.
D. Review of the facility policy "Patient Care Planning" for Swing-beds on 10/30/14 revealed "A care plan will be initiated on day of admission." The care plan policy stated that the care plan will be "consistent with the physician's plan of medical care."