HospitalInspections.org

Based on review of facility personnel records and interview with staff it was determined the facility failed to ensure Patient Care Technicians (PCT) were competent to provide the skills necessary to meet the needs of patients admitted to the facility. This affected 1 of 1 PCT's and had the potential to negatively affect all patients served by the facility.

Findings include:

Review of the personnel record of Employee Identifier (EI) # 7, PCT, hire date 04/28/16, revealed no documentation a skills competency was completed.

The personnel record was also reviewed by EI # 2, Chief Executive Officer, who confirmed there was no skills competency checklist in the file.

EI # 2 was given the opportunity to provide the skills checklist to the surveyor by 10:00 AM on 4/28/17. The skills checklist for EI # 7 was not provided.

Based on medical record review and interview with staff it was determined the facility failed to ensure:

1. Physician ordered therapeutic diets were specific to meet the needs of each patient.

2. Orders for supplemental oxygen included the flow rate and method of administration.

This affected 3 of 15 inpatient records reviewed including Patient Identifier (PI) # 28, PI # 19 and PI # 29 and had the potential to negatively affect all patients admitted to the facility.

Findings include:

1. PI # 28 was admitted to the facility 2/3/17 with diagnoses including Pneumonia, Chronic Obstructive Pulmonary Disease and Congestive Heart Failure.

Review of the physician's orders dated 2/3/17 at 11:08 AM revealed Diet Order: Diabetic Diet. There was no documentation of the specific calorie limitation to meet the dietary needs of the patient.

Review of the nursing documentation revealed no documentation the patient's dietary intake and meal tolerance was assessed.

Further review of the physician's orders dated 2/3/17 revealed Respiratory Order: Oxygen ongoing. There was no documentation of the specific flow rate and delivery method required to meet the respiratory needs of the patient.

Review of the nursing documentation revealed the oxygen was administered at 2 L/M (liters per minute) per n/c (nasal cannula) on 2/4/17; 3 L/M on 2/5/17; 2 L/M on 2/6/17 and not documented on 2/7/17. Further review of the nursing documentation revealed no documentation of the patient's use of oxygen or not on the 7 PM to 7 AM shifts.

An interview conducted on 4/27/17 at 10:00 AM with Employee Identifier (EI) # 1, Director of Nursing, confirmed the above findings.



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2. PI # 19 was admitted to the facility on 4/23/17 with an admitting diagnosis of Anemia.

Review of the nursing assessment dated 4/23/17, 4/24/17 and 4/25/17 revealed the nurse documented the patient was on Oxygen (O2) at 2 l (liters)/ (per) NC (nasal cannula).

Review of the physician order dated 4/25/17 revealed the following order: "Oxygen on going". There was no documentation of the liter of flow or how the Oxygen was to be delivered to the patient.

An interview was conducted on 4/27/17 at 1:30 PM with EI # 1 who confirmed the above mentioned findings.

3. PI # 29 was admitted to the facility on 2/7/17 with admitting diagnoses of Altered Mental Status and Pneumonia.

Review of the physician order dated 2/8/17 revealed an incomplete order for Oxygen as follows: "Oxygen cannula, adult ongoing".

Review of the nursing assessment dated 2/11/17 at 7:14 PM revealed the nurse documented the patient was on O2 at 3 l/NC. Further review of the physician orders revealed no documentation the order was written for the oxygen at 3 l/NC.

Review of the nursing assessment dated 2/11/17 at 11:14 PM revealed the nurse documented O 2 at 4 l per simple mask. Further review of the physician orders revealed no order written for the O2 by simple mask.

Review of the nursing assessment dated 2/12/17 revealed the nurse documented Oxygen at 6 l /NC.
Further review of the physician orders revealed no documentation a physician order was written.

An interview was conducted on 4/27/17 at 11:30 AM with EI # 1 who confirmed the above mentioned findings.

Based on review of medical records, a tour of the dietary area, The United States Public Health food Code 2013 regulations, observations and interviews it was determined the Dietary Department failed to ensure the food was stored in a safe and sanitary manner. This had the potential to negatively affect all patients served by the hospital.

Findings include:

United States Health Public Food Code 2009

3-501.17 Ready-to-Eat, Potentially Hazardous Food
(Time/Temperature Control for Safety Food),
Date Marking.
...commercially processed food open and hold cold
(B) Except as specified in ¶¶ (D) - (F) of this section, refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in
¶ (A) of this section and: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Pf and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety...
(C) A refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) ingredient or a portion of a refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest- repared or first prepared ingredient. Pf
(D) A date marking system that meets the criteria stated in ¶¶ (A) and (B) of this section may include:...
(2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under ¶ (A) of this section;
(3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under ¶ (B) of this section...

During a tour of the dietary department on 4/26/17 at 10:30 AM with the Dietary Manager, Employee Identifier (EI) # 6, the surveyor observed in the dry storage area:

1 - 10 pound (lb) box of spaghetti opened with no date when it was opened

In the large freezer:
1 blue bag of turkey sausage not labeled
1/2 box country fried steaks not labeled
1 bag beef patties not labeled
1 bag of carrots expired 4/23/17
1 bag of okra expired 4/2/17
1 bag of ham slices not labeled
1 bag of mixed vegetables expired 1/13/17
2 bags of a red sauce not labeled with contents or date
1 bag breaded okra expired 4/9/17
1 bag of carrots expired 12/14/16
1/2 bag of tomato sauce expired 2/15/17
1 bag of tomato sauce not labeled
1 slice of ham date rubbed off

In the refrigerator:
2 gallon bucket of hamburger pickles open with no label
1 box of tomatoes open with no date received
2 1/2 flats of eggs with no date received
7 slices of sweet potatoes pie with expiration date of 4/24/17

In the pantry area:

1 16 ounce (oz) bottle Lowery's seasoning salt no date
1 17 oz smoked paprika no date
1 35 oz bottle of meat tenderizer no date
1 bottle Moore's marinade sauce no date

An interview was conducted on 4/26/17 at 12:15 PM with EI # 6 who confirmed the above mentioned findings.

Based on review of the Nutritional Assessments for the months of January, February, March and April 2017 and interviews with the staff it was determined the facility failed to ensure Employee Identifier (EI) # 10 Dietitian, reviewed and signed each Nutritional Assessment for each patient which was completed by EI # 6, Dietary Manager. This had the potential to negatively affect all patients served by the facility.

Review of the Nutritional Assessments on 4/27/17 at 9:00 AM revealed the Dietitian failed to review and sign all nutritional assessments completed by EI # 6 during the months of January, February, March and April 2017.

An interview was conducted on 4/27/17 at 10:30 AM with EI # 1, Chief Nursing Officer, who confirmed the above mentioned findings.

Based on medical record review and interview with staff it was determined the facility failed to ensure physician ordered therapeutic diets were specific to meet the needs of each patient.
This affected 1 of 15 inpatient records reviewed including Patient Identifier (PI) # 28 and had the potential to negatively affect all patients admitted to the facility.

Findings include:

1. PI # 28 was admitted to the facility 2/3/17 with diagnoses including Pneumonia, Chronic Obstructive Pulmonary Disease and Congestive Heart Failure (CHF).

Review of the physician's orders revealed an order dated 2/3/17 at 11:08 AM Diet Order: Diabetic Diet. There was no documentation of the specific calorie limitation to meet the dietary needs of the patient.

Further review of the physician's orders revealed an order on 2/6/17 for nutrition consult CHF.

Review of the medical record revealed documentation under Nursing Assessment on 2/6/17 "Dietitian Assessment: reviewed current diet: 2000 cal (calorie) ADA (American Diabetic Association), current supplements diabetic diet...weight 291.4...Recommendations change diet to: 1200 calorie to help promote weight loss." Signed by Employee Identifier (EI) # 6, Dietary Manager.

There was no documentation in the Dietitian Assessment regarding the CHF diagnoses which was the reason for the dietary consult and no documentation in the medical record the physician reviewed or was aware of the dietary recommendation.

Review of the medical record revealed no documentation the patient's consumption of meals and/or tolerance of the therapeutic diet was assessed.

Review of the facility documentation from the consulting Registered Dietitian (RD) revealed no evidence the RD reviewed the patient's therapeutic diet order nor the patient's dietary assessment completed by the dietary manager.

An interview was conducted on 4/27/17 at 12:30 PM with EI # 2, Chief Executive Officer, who confirmed 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. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations
Refer to A 0724

Based on observations, review of facility policy and interviews with facility staff it was determined the facility failed to ensure equipment was monitored to maintain safety of patients and staff. This had the potential to affect all patients.

Findings include:

"Policy and Procedure Form
Subject: Preventive Maintenance

Policy: There shall be a Preventive Maintenance (P.M.) Program for all Jackson Medical Center Hospital equipment.

Procedure:
1. A current Hospital Equipment listing shall be reviewed to identify and locate equipment.

2. A Hospital P.M. Form and Maintenance Record shall be accomplished for each piece of equipment. Manufacturer's recommendation, pertinent codes, safety considerations, and equipment reliability history shall be the basis for determining P.M. requirements.

3. P.M. shall be accomplished at prescribed intervals..."

"Policy and Procedure Form
Subject: Crash Cart Checks

Purpose: To ensure that the crash cart equipment, drugs, and supplies are functional, stocked appropriately, and in date.

Procedure:
1. Ensure that all equipment on the formulary is present and functioning properly at the beginning of each shift. (Monitors, Airway equipment, etc.)

3. Check expiration dates on supplies and drugs on the first day of every month..."

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1. During a tour of the inpatient unit conducted on 4/25/17 at 11:00 AM with Employee Identifier (EI) # 2, CEO (Chief Executive Officer), multiple infusion pumps were observed throughout the unit with no evidence of preventive maintenance (PM) or with PM stickers more than 1 year old.
Additionally, an EKG (electrocardiogram) machine located in the hallway had a PM sticker dated 1/2016 which was the last PM conducted..

2. During a tour of the Emergency Department conducted 4/26/17 at 11:00 AM with EI # 1, Director of Nursing, and EI # 3, Registered Nurse (RN) the surveyor observed an infusion pump in ER Room 2 with a PM sticker dated 1/16 and an infusion pump in ER Room 3 with no PM sticker.

The surveyor asked if an inventory log was available for the infusion pumps and EI # 3 stated when there was a problem with a pump it was removed from service, a request for repair form was completed and attached to the pump and when 5 or 6 pumps were out of service they were sent back to the manufacturer for repair.

There was no inventory log maintained to identify the pumps nor to document preventive maintenance.



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3. During a tour of the Medical/Surgical area on 4/26/17 at 8:30 AM the crash cart on the medical/surgical area was checked. While checking each drawer for expired medications and supplies the following expired medication and supplies were found:

Calcium Gluconate expired 2/17
2 - Arterial Blood Kits expired 2/17
2 - ET (endotracheal) tubes 12 Fr (french) expired 9/14
1 - 14 Fr ET tube expired 9/14
1 16 Fr ET tube expired 3/14
1 - 18 Fr ET tube expired 6/14
2 - 20 Fr ET tubes expired 9/14
1 - 22 Fr ET tube expired 9/14
3 - scalp vein set 21 gage expired 8/13
4 - scalp vein sets 23 gage expired 4/14
4 - 18 gage vacutainer needles expired 8/12
2 - 24 gage vacutainer needles expired 12/12
5 - 22 gage vacutainer needles expired 2/13
3 - 20 gage vacutainer needles expired 11/12

An interview was conducted on 4/26/17 at 11:00 AM with EI # 1, Chief Nursing Officer, who confirmed the above mentioned findings.

Based on the Centers for Disease Control and Prevention Hand Hygiene recommendations, observations and interview with staff it was determined the facility failed to ensure dietary and housekeeping staff performed hand hygiene after removing gloves. This had the potential to affect all patients admitted to the facility.

Findings include:

"Centers for Disease Control and Prevention
Morbidity and Mortality Weekly Report
October 25, 2002 / Vol. 51 / No. RR-16

Guideline for Hand Hygiene in Health-Care Settings

Recommendations and Reports

Rationale for hand hygiene:
Potential risks of transmission of microorganisms to patients

Potential risks of health-care worker colonization or infection caused by organisms acquired from the patient

Morbidity, mortality, and costs associated with health-care-associated infections

Indications for hand hygiene:
Contact with environmental surfaces in the immediate vicinity of patients...

After glove removal...
Decontaminate hands after contact with inanimate objects..."

1. During observations on 4/26/17 at 10:50 AM of terminal room cleaning by Employee Identifier (EI) # 5, Housekeeping, the surveyor observed EI # 5 remove gloves and re-glove on multiple occasions without performing hand hygiene.




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2. An observation was conducted on 4/26/17 at 10:30 AM in the Dietary Department. On arrival to the department EI # 8, Dietary Aide was washing the pots and pans at the 3 compartment sink. Once complete EI # 8 removed gloves and failed to sanitize or wash hands prior to donning a clean pair of gloves.

During the observation EI # 9, Dietary Aide was assisting with recording of the food temperatures in the log book. Once complete EI # 9 removed gloves and failed to sanitize hands or wash hands prior to donning clean gloves and assisting with the plating of food.

An interview was conducted on 4/26/17 at 12:15 PM with EI # 6, Dietary Manager, who confirmed the above mentioned findings.

Based on facility policy and procedure, medical record review and interview with staff it was determined the facility failed to demonstrate evidence of an ongoing activities program with scheduled activities to promote quality of life for patient's admitted to the swing-bed program. This affected 1 of 1 sampled patients, Patient Identifier (PI) # 23, and 2 of 2 unsampled patients and had the potential to affect all patient's admitted to the facility's swing-bed program.

Findings include:

"Policy and Procedure Form
Subject: Activities

Purpose: To promote maintenance or enhancement of each resident's quality of life.

Procedure:
Activities are planned to meet the needs and interest of the patient, both men and women
Activities are scheduled based on the needs of the patient and consider religious and cultural interest...
Activities are provided in individual and group settings"

1. PI # 23 was admitted to the facility's swing-bed program 3/14/17 with diagnoses including Cervical Laminectomy and Asthenia.

Review of the medical record revealed an activities plan developed on 3/14/17 with activity recommendations of TV (television) and reading 1-2 times weekly.

Review of the medical record revealed no documentation the activities were offered / provided.

An interview was conducted 4/27/17 at 10:00 AM with Employee Identifier (EI) # 4, Program Director, who confirmed activities should be documented in the medical record. EI # 4 stated the designated activities PCT (Patient Care Technician) took the activities cart to the patients' room each Tuesday and Thursday. EI # 4 reviewed the EMR (electronic medical record) for PI # 23 and 2 additional unsampled swing-bed patients and was unable to locate documentation that activities were provided as required.