HospitalInspections.org

Based on emergency room (ER) record review, observation, facility policy and procedure, and staff interview, it was determined the facility failed to ensure 2 of 10 ER patients were informed of the patient's rights prior to receiving care at the facility. This affected Patient Identifier (PI) #2 and an unsampled patient # 1 and has the potential to affect all patients served by facility.

Findings include:

Facility Policy:
Subject: Consent Forms
Date Issued: March 1, 2018

Policy Description: It is the policy of Hale County Health Care Authority to get signatures on consent to Treat... Registration clerks are required to inform the patient what they are signing and a copy of the consent forms are available for patient viewing.

Procedure: The current consent forms pertaining to Registration and Admissions are:

1. Consent to Treat...

Obtaining the signature: To properly inform patient of the information contained in the consent, registrars must utilize the following script to inform the patient of the need for Signed Consent/Agreement to Pay:

"We'll need to get your consent for your treatment today. This signature covers your consent for treatment as well as your HIPAA privacy Statement. Do you wish to place any restrictions on your personal health information being used by this hospital to carry out your treatment, payment, or health care operations? This also means we cannot release your information to callers or visitors during your stay here."

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1. A review PI # 2 ER record revealed no documentation that the consent for treatment had been discussed with the patient nor was there any documentation that the consent for treatment was provided to the patient or their representative before they received care at the hospital.

2. An observation was conducted on 5/15/18 at 12:05 PM with Employee Identifier (EI) # 11, registration clerk, and an unsampled patient # 1 for observation of the ER registration process.

The unsampled patient # 1 was brought into ER registration room.

EI # 11 spoke with unsampled patient # 1 for several minutes about his/her demographic information and reason for ER visit. EI # 11 then asked the unsampled patient # 1 to sit in lobby for the nurse without any discussion about registration paperwork, including the consent for treatment.

EI # 11 then gathered registration paperwork, including the consent for treatment form, and placed on a clipboard.

Surveyor asked EI # 11 about when the consent for treatment is signed. EI # 11 showed surveyor the second page of paperwork, which was identified by surveyor as the consent for treatment form.

The consent for treatment form contained no patient signature but did have witness signature filled out with signature of EI # 11. EI # 11 then stated, "Patient will sign with nurse." EI # 11 then placed registration paperwork, with consent for treatment form, on counter of nurses station.

At 1:00 PM on 5/15/18 unsampled patient # 1 was taken to triage room with EI # 3, Clinical Nurse Manager.

EI # 3 spoke with unsampled patient # 1 for several minutes about the reason for ER visit and documented in Electronic Medical Record (EMR).

After documentation, EI # 3 obtained vital signs and oxygen saturation (O2 sat). EI # 3 then documented vital sign information in the EMR.

EI # 3 then lead unsampled patient # 1 to ER # 1 exam room to wait for physician.

After unsampled patient # 1 was placed in ER # 1, surveyor asked to see registration paperwork.

EI # 3 then went to nursing station, obtained still blank paperwork including consent for treatment and showed surveyor. Surveyor did verifiy the consent for treatment continued to have no patient signature.

EI # 3 then went into ER # 1 and handed the unsampled patient # 1 the paperwork, including the consent for treatment, and stated to patient "fill the paperwork out." EI # 3 then exited ER # 1 room.

EI # 3 and EI # 11 failed to inform the patient about the consent for treatment form prior to asking for the patient signature. Patient signature was not properly witnessed on form due to EI # 11 signature in the witness section of form prior to patient signing.

An interview was conducted on 5/17/18 at 11:15 AM with EI # 2, Director of Patient Care Services, confirmed the aforementioned findings.

Based on observation, review of agency policy, and interviews, it was determined Registered Nurse (RN) failed to administer medications within appropriate time frames per facility policy.

This affected 1 of 5 medication pass observations and did affect an unsampled patient, and had the potential to negatively affect all patients treated at the facility.

Findings include:

Policy: Prescribing/Ordering - General Practices
Reference Number: 6351
Revised Date: None

Standard Administration Times:

"Unless otherwise specified, doses shall be administered at the follwoing times:

Daily, administration times - 9:00 AM...
TID (3 times a day), administration times - 9:00 AM, 1:00 PM, 5:00 PM...
Every 12 hours, administration times - 9:00 AM, 9:00 PM..."

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1. On 5/17/18 at 10:40 AM, EI # 3, Clinical Nurse Manager, informed the surveyor EI # 9, Registered Nurse (RN), was ready for a medication pass observation to an unsampled patient on the medical floor.

The following medications were ordered for 9:00 AM and were administered at 10:48 AM, 48 minutes late:

Amlodipine 5 milligram (mg) every AM.
Aspirin 81 mg every AM.
Brilinta Oral 90 mg every AM.
Diphenhydramine Oral 25 mg 3 times per day.
Famotodine IV 20 mg every 12 hours.
Heparin Subcutaneous 5,000 units every 12 hours.
Losartan Oral 25 mg every day.
Metoprolol Oral 50 mg every day.

The medications were administered to the patient at 10:48 AM, 48 minutes after the agency acceptable times for administration. EI # 1, RN, Cheif Operating Officer, confirmed the RN administered the patient's medications late.

In an interview conducted on 5/17/18 at 3:00 PM with EI # 1, confirmed the above findings and stated the nurses may administer medications 1 hour before or 1 hour after the agency administration times.

Based on observations, review of agency policyand procedure, the Narcotic Drug Signature Record, and staff interviews, the facility failed to ensure the staff documented the counting of the Narcotic Drug Floor stock supply for the Medical Unit during May 2018. This had the potential to negatively impact all patients served by the facility.

Findings include:

Policy: Controlled drug Distribution
Reference Number: 6204
Revised Date: None

Procedure: ...Dispensing to Patient Care Units:

"...All controlled drugs in Schedules II, III and IV shall be stored in double locked security...

Each dispensing and each drug administration transaction shall be recorded separately...

The perpetual inventory record for floor stock controlled drugs in Schedules II, III, and IV shall be verified by two nurses at each change of shift."

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On 5/16/18 at 12:45 PM, the surveyor and Employee Identifier (EI) # 4, Pharmacy Technician, inspected the Narcotic Drug supply cabinet on the Medical Unit and the Narcotic Drug Signature Record book.

EI # 4 stated each day at the beginning of the 7:00 AM and 7:00 PM shifts, the Registered Nurse (RN) going off duty counts the Medical Unit Narcotic cabinet drugs with the RN coming on duty and both of them sign the Narcotic Drug Signature Record.

Review of the Narcotic Drug Signature Record on 5/16/18 at 12:50 PM revealed the following dates without an Registered Nurse (RN) signature denoting the Medical Unit narcotic cabinet contents were counted:

5/11/18 no signature from the "Nurse Coming on Duty" at 7:00 PM.
5/14/18 no signature from the "Nurse Coming on Duty" at 7:00 PM.
5/15/18 no signature from the "Nurse Coming on Duty" at 7:00 PM.

An interview was conducted on 5/17/18 at 3:00 PM with EI # 1, Chief Operating Officer, who confirmed the above findings.

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

1. Ensure Security and Accountability of emergency crash carts.

2. Provide the patients with a method of alerting staff for needs while being treated in the Emergency Room (ER) due to not having operable Call System.

3. Monitor freezer in Outpatient Therapy for appropriate temperature controls.

4. Ensure Preventive Maintenance (PM) was maintained on all equipment.


Findings include:

Facility Policy:

Subject: Emergency Crash Cart Security and Accountability

Effective: 3/1/2018

Policy: The nursing staff shall visually inspect the numbered break-away lock located on the crash cart at each change of shift, documenting that the cart is properly locked with all appropriate contents present and intact

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1. A tour of the Emergency Department (ED) was conducted on 5/15/18 at 12:00 PM.

The surveyor observed 5 private treatment rooms within the ED with a door to close for privacy. The patients' beds were not visible from the nurses' station.

The ED had a total of 5 out of 5 private treatment rooms that contained no operational call lights at the bedside.

The surveyor reviewed the ER Crashcart Checklist for March 2018, April 2018, and May 2018. There was no documentation the Crashcart was checked on the following shifts as directed per the facility checklist:

7:00 AM on 3/9/18, 3/21/18, 4/2/18, 4/3/18, 4/4/18, 4/7/18, 4/9/18, 4/10/18, 4/15/18, 4/23/18, 4/25/18, 5/8/18, and 5/14/18

7:00 PM on 3/3/18, 3/11/18, 3/30/18, 4/2/18, 4/4/18, 4/13/18, and 5/13/18

The surveyor observed all ED equipment for PM. The following equipment in the ED was without documentation of a PM:

ER # 1- nebulizer

ER # 2- nebulizer

Triage Room- baby weight scale and adult weight scale

An interview was conducted 5/17/18 at 11:15 AM with Employee Identifier (EI) # 2, Director, Patient Care Services, who confirmed the facility failed to provide the patients with a method of alerting staff for needs while being treated in the ER due to not having operable Call System, failed to ensure the security and accountability of emergency crash carts, and ensure PM was maintained on all equipment.



2. A tour of the Outpatient Therapy Department was conducted on 5/16/18 at 11:45 AM with EI # 8, Rehab Director.

The surveyor observed a freezer used to store ice packs in the outpatient therapy department. Surveyor asked EI # 8 to see temperature logs of freezer. EI # 8 verbalized they did not have a temperature log for freezer.

EI # 8 then verified the facility failed to ensure appropriate temperature control for freezer.





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5. A tour of the Dietary Department was conducted on 5/15/18 at 11:25 AM. There was no PM stickers observed on the Refrigerator or 2 Freezers containing food for patients.

An interview was conducted on 5/16/18 at 8:20 AM with EI # 7, Dietary Manager, and EI # 12, Dietary Director. EI # 7 stated the equipment was checked quarterly by the maintenance department, but no documentation was maintained.

6. On 5/16/18 at 9:10 AM the surveyor observed a breathing treatment administered to an unsampled patient by EI # 9, RN (Registered Nurse).

A review of the Medline Nebulizer machine used to deliver the breathing treatment, located in the patient's room, revealed no PM sticker.

An interview was conducted on 5/17/18 at with EI # 2, Director, Patient Care Services, who confirmed the above findings.

7. On 5/15/18 at 1:00 PM the emergency crash cart located at the East Wing nurses station was reviewed.

The surveyor observed the yellow plastic lock to be linked in the chain only, and did not secure the cart. The surveyor was able to open the cart, without breaking the lock.

Review of the Crashcart Checklists for March 2018, April 2018, and May 2018 revealed the following shifts did not sign the checklist per facility policy:

7:00 AM: 3/7/18, 3/8/18, 3/13/18, 3/21/18, and 3/31/18.

7:00 PM: 3/17/18, 3/24/18, 3/25/18, 3/30/18, 4/14/18, 4/26/18, 5/6/18, 5/9/18, and 5/10/18.

An interview was conducted on 5/17/18 at 2:00 PM with EI # 2, who confirmed the above findings.



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8. On 5/16/18 at 2:10 PM a tour of the Central Sterile Department was conducted with EI # 6, Licensed Practicle Nurse (LPN)/Sterile Processor. The surveyor observed the following equipment without documentation of a PM:

The Validator Plus Autoclave

An interview was conducted on 5/17/18 at 3:00 PM with EI # 1, Cheif Operating Officer, who confirmed the above finding.

Based on facility policies, observations and interviews, it was determined the facility staff failed to follow infection control procedures and:

1. Perform hand hygiene when appropriate.

2. Dispose of used supplies appropriately in the Emergency Room (ER) Department.

3. Clean medication/ computer cart after use in patient rooms.

This had the potential to affect all patients served by the facility and did affect, Unsampled Emergency Room (ER) patients ( # 1, # 2, # 3), PI # 13, and PI # 16.

Findings include:

Policy: Hand Hygiene- CDC Guidelines

Date Revised: None listed

Purpose: To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs, and infections.

Policy:
...All staff shall use the hand-hygiene techniques, as set forth in the following procedure....
...Before each patient encounter..
...After coming in contact with patient's intact skin, i.e., taking a patient's blood pressure, pulse, lifting/moving the patient

Policy: Infection Prevention and Control

Date Revised: None listed

The hospital's general infection prevention and control policies and procedures are adhered to...

Patient care Equipment and Supplies:

Disposables:

All disposable items/supplies are for one patient use only, and are discarded as appropriate (regular waste versus medical waste).

...Environmental Cleaning:

Counter and work tables:

Damp wipe with approved disinfectant solution daily, after use and as needed."

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1. An observation was conducted on 5/15/18 at 1:00 PM with Employee Identifier (EI) # 3, Clinical Nurse Manager, and unsampled patient # 1 for observation of the ER registration.

At 1:00 PM on 5/15/18, the unsampled patient # 1 was taken to triage room with EI # 3, Clinical Nurse Manager.

EI # 3 spoke with patient for several minutes about the reason for ER visit and documented in Electronic Medical Record (EMR). After documentation, EI # 3 obtained vital signs and oxygen saturation (O2 sat) without performing hand hygiene prior to patient contact.

EI # 3 then documented vital signs and O2 sat in EMR without performing hand hygiene after patient contact.

EI # 3 then lead the unsampled patient # 1 to ER # 1 and went to nursing station to obtain paperwork on clipboard, clipboard is used for multiple patients in the ER, for the patient to fill out without performing hand hygiene after patient contact.

An interview conducted on 4/12/12 at 11:10 AM with EI# 1, Director of Nursing, confirmed the aforementioned findings.


2. A tour of the Emergency Department was conducted on 5/15/18 at 12:00 PM with EI # 1.

On the observation of ER # 1 room, a laboratory specimen biohazard bag, containing an opened suture removal kit and Iodoform packing strips were found with an unsampled patient # 3 name inside of bag. The laboratory specimen biohazard bag, with contaminated supplies inside, was found at the back of a cabinet with clean supplies beside bag.

Facility failed to dispose of supplies for one patient use only appropriately and stored items with clean supplies.

An interview conducted on 4/12/12 at 11:10 AM with EI # 1, confirmed the aforementioned findings.



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3. During observation of medication passes performed on 5/16/18 at 8:10 AM, on an unsampled patient, EI # 6, LPN (Licensed Practical Nurse) rolled the medication/ computer cart into the patient's room and prepared medications for administration. The medications administered included 4 medicines taken by mouth and one subcutaneous injection. Following the administration of all medicines, EI # 6 rolled the cart back to the nurses' station without cleaning the work surface of the cart, and continued to chart on the computer.

During an interview on 5/17/18 at 2:00 PM with EI # 2, Director, Patient Care Services, the above findings were confirmed.

4. PI # 13 was admitted to the facility on 5/14/18 with diagnoses including Unsteady Gait, Functional Strength Deficit, and Congestive Heart Failure.

On 5/16/18 at 9:10 AM the surveyor observed EI # 9, RN (Registered Nurse) administer medications to PI # 13. EI # 9 rolled the medication/ computer cart into the patient's room. Medications administered included eye drops and 10 medications by mouth. Following the administration of all medications, EI # 9 collected the pill wrappers and used cup from the top of the cart and placed the items in the garbage. EI # 9 then rolled the cart into MR # 16's room without cleaning the work surface of the cart, according to policy. EI # 9 proceeded to administer medications to PI # 16.

During an interview on 5/17/18 at 2:00 PM with EI # 2, Director, Patient Care Services, the above findings were confirmed.

5. PI # 16 was admitted to the facility on 5/14/18 with the diagnoses of Pneumonia.

On 5/16/18 at 9:35 AM the surveyor observed EI # 9, administer medication to PI # 16. EI # 9 rolled the medication/ computer cart into the patient's room. Medications administered included 2 by mouth, one IV (Intravenous), and one by nebulizer. Following administration of the medications, EI # 9, rolled the cart back to the nurses' station and failed to clean the work surface of the cart, per facility policy.

During an interview on 5/17/18 at 2:00 PM with EI # 2, Director, Patient Care Services, the above findings were confirmed.