The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

NORTH METRO MEDICAL CENTER 1400 BRADEN STREET JACKSONVILLE, AR 72076 Dec. 3, 2015
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on policy and procedure review, document review and interview, it was determined the Facility failed to protect and promote the rights of patients in that a procedure was performed without patient consent, was performed by Physician #1 who was not credentialed or privileged to perform the procedure and the procedure was not performed per policy and procedure. Failure to ensure patient consent was obtained prior to the procedure did not allow Patient #1 to make an informed decision regarding the effects and side effects of the procedure; failure to ensure Physician #1 was currently credentialed and privileged to perform the procedure and perform it per established Facility policy and procedure had the potential for unnecessary adverse effects. See CMS A-0131 and A-0144 for details.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on clinical record review, policy and procedure review and interview, it was determined the Facility failed to obtain procedural consent for one of one patient (Patient #1) undergoing a Therapeutic Phlebotomy. Failure to obtain consent for the removal of blood did not allow Patient #1 to be knowledgeable of health status, prognosis and possible side effects of the procedure. The failed practice affected Patient #1 on 10/28/15. Findings follow:

A. Review of Patient #1's clinical record revealed Patient #1 underwent a Therapeutic Phlebotomy on 10/28/15. Review of the clinical record revealed no consent for the procedure.

B. The policy and procedure for consents was requested at 0943 on 12/03/15. The policy and procedure was received from the Quality & Risk Director at 0945. Review of the policy and procedure revealed the following:...
II. PROCEDURE:
A. WHEN AN INFORMED CONSENT / AUTHORIZATION IS REQUIRED
1. All medical treatment requires a signed authorization by the patient or person authorized to give informed consent on behalf of the patient.
2. The following procedures required an additional signed consent/authorization:
a. All special /invasive procedures.

EXAMPLE: Lumbar puncture, blood transfusions, proctoscopy, EGD (esophagogastroduodenoscopy), etc. ...

C. An interview was conducted with the CNO and Quality & Risk Director at 1010 on 12/03/15. Both were asked to find the consent or permit for the Therapeutic Phlebotomy in Patient #1's clinical record. Both looked and stated there was not one. Both were asked if there should have been a consent obtained and both stated yes per policy a consent should have been obtained from the Patient #1.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on clinical record review, Physician #1 privileges, policy and procedure review, Laboratory competencies and interviews it was determined the Facility failed to ensure Patient #1 received care in a safe setting in that a procedure was performed without her consent, was performed by Physician #1, who was not credentialed or privileged to perform the procedure, the procedure was not performed per policy and procedure and the blood removed from Patient #1 was not placed in an appropriate container during removal and for transport. Failure to ensure patient consent was obtained prior to the performed procedure did not allow the patient to be knowledgeable regarding the treatment and possible side effects; failure to ensure Physician #1 performing the procedure was credentialed and privileged to perform the procedure did not ensure a knowledgeable person was performing the procedure per policy and procedure. The failed practice affected Patient #1 on 10/28/15. Findings follow:

A. Review of Patient #1's clinical record revealed a progress note authored by Physician #1 on 10/28/15 detailing the performance of a Therapeutic Phlebotomy.

B. Review of the clinical record revealed no consent for the procedure was in the record. In an interview, at 1010 on 12/03/15, conducted with the Chief Nursing Officer (CNO) and the Quality & Risk Director they verified the above findings.

C. Physician #1's current clinical privileges were requested and received from the CNO at 1520 on 12/02/15. Review of the clinical privileges revealed no mention of blood administration or Therapeutic Phlebotomy. The attached letter dated 11/19/14 revealed the following: "...On behalf of the Board of Directors, I am pleased to inform you that you have been granted the increased privileges requested to include Internal Medicine privileges to work as a Hospitalist. Your appointment will continue until August 31, 2015. ..."

D. Review of the policy and procedure titled "Therapeutic Phlebotomy" received from the Laboratory Director at 0900 on 12/01/15 revealed the following:
POLICY:
This term is used when phlebotomy is done for medical indications. The medical records must include the request from the patient's physician specifying the amount of blood to be drawn and contain the permit which is signed when admitted . A hematocrit will be performed before performing the phlebotomy. Therapeutic Phlebotomies may only be performed by personnel who have been approved by the Medical Director. Therapeutic Phlebotomies may be performed at any available empty observation bed on a nursing unit (call the admissions nurse, 7003 to obtain room number). The emergency room is an alternate site if observation beds are not available.
EQUIPMENT:
Alcohol pads
Povidone-iodine solution (SEPPS)
2x2 (2 inches by 2 inches) gauze pads
1" (inch) tape
Tourniquet
Two containers of juice (obtained from Dietary Department)
Blood Collection Bag (ACD, CPDA, or Adsol) (obtained from ARK Red Cross)
PROCEDURE: ...
12. Dispose of blood in lab in contaminated bag container and log the phlebotomy in the blood bank log, example name, id (identification), "500 ml removed from the right arm" "date, initial" Also, document on the requisition the same information as above.
RESULTING PHLEBOTOMY:
1. Result phlebotomy in the Blood Bank module. Access result entry by following the BBK Quick Start Manual page 21.
2. Right fat arrow over by Therapeutic Phlebotomy. Enter the following information: H & H (hemoglobin and hematocrit), approximate number of ccs (cubic centimeter) removed, what was given for fluid replacement, how long patient was observed and condition of patient at the time of discharge.
3. Make a copy of the physician order containing diagnosis and a copy of patient consent to keep with phlebotomy results in the lab.

E. Review of the competency documents received from the Laboratory Director at 0910 on 12/03/15 did not reveal competency documents for Physician #1.

F. During an interview with MT (Medical Technologist) #1 at 1405 on 12/02/15 she stated the Phlebotomist was on One East Unit on 10/28/15 when she was handed a trash bag of blood by Physician #1 and told to dispose of it. The Phlebotomist brought the blood back to the lab where it was placed in a biohazard bag, labeled and dated.
VIOLATION: MEDICAL STAFF Tag No: A0338
Based on interview and document review, it was determined the Medical Staff allowed Physician #1 to practice from September 1, 2015, through December 03, 2015 with expired privileges. Failure to ensure Physician #1 was currently privileged did not ensure Physician #1 was trained, qualified and competent by Medical Staff standards to practice in the Facility. See CMS A-0340.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview, review of physician privileges, document review and policy and procedure review, it was determined the Governing Body allowed Physician #1 to practice with expired privileges, to perform a procedure he was not privileged to perform, perform the procedure without patient consent and perform it incorrectly per the Facility's established policy and procedure. See CMS A-0115, A-0131, A-0144, A-0338 and A-0340.
VIOLATION: MEDICAL STAFF CREDENTIALING Tag No: A0341
Based on interview and document review, it was determined Physician #1 was practicing as an Internist and Emergency Medical Physician without current privileges. Failure to ensure Physician #1's privileges were current did not ensure Physician #1 was trained and qualified to perform the requested procedures. The failed practice affected all patients treated by Physician #1 from September 1, 2015, through December 03, 2015. Findings follow:

A. An interview was conducted with the Chief Nursing Officer (CNO) and the Quality and Risk Manager at 1515 on 12/0/215. The current privileges of Physician #1 were requested and received from the CNO at 1520 on 12/02/15. Review of the clinical privileges revealed no mention of blood administration or Therapeutic Phlebotomy. The attached letter dated 11/19/14 revealed the following: "... On behalf of the Board of Directors, I am pleased to inform you that you have been granted the increased privileges requested to include Internal Medicine privileges to work as a Hospitalist. Your appointment will continue until August 31, 2015. ...".
B. Review of the clinical record of Patient #1 revealed Physician #1 did not follow the Facility policy and procedure when Physician #1 performed a Therapeutic Phlebotomy. Physician #1 did not obtain a written consent from Patient #1 prior to performing the procedure; Physician #1 did not disperse the blood into the proper container while removing the blood and placed it in a trash can for disposal.
C. During an interview with the Lab Director at 0800 on 12/03/15 the Lab Director stated employees must be competent to perform a Therapeutic Phlebotomy. Review of the competencies provided by the Lab Director at 0910 on 12/03/15 did not reveal competencies for Physician #1.
D. Physician #2, Facility Medical Director of the Lab, stated during a telephone interview conducted at 1300 on 12/04/15 consent is required prior to the Therapeutic Phlebotomy and the procedure was never an emergent procedure.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observations and interview it was determined the Facility failed to maintain isolation precautions in one of one (Patient #6) isolation room in that the Facility failed to ensure the carts for contaminated linens and disposables were next to the exit. Failure to ensure the carts were next to the exit allowed staff to cross the room without shoe coverings, gowns and gloves to exit the room. The failed practice had the potential to affect all patients, visitors and staff on the One East Unit on 12/02/15. Findings follow:

A. While observing medication administration in an isolation room, the soiled linen cart and the disposable items cart were observed to be on the opposite side of the exit in Room 101.
B. At 0940 on 12/02/15 Registered Nurse #1 was observed to stand at the foot of the bed in Room 101, remove her gown, shoe covers and gloves, place them in the disposable items cart and walk across the room out to the hallway. During an interview with the Quality and Risk Manager at 1010 on 12/02/15 she verified the carts should have been next to the exit.



Based on observations and interview it was determined the Facility failed to ensure proper cleaning of equipment occurred after patient use. Failure to ensure equipment was cleaned after each patient contact had the potential to allow the development and spread of infection. The failed practice had the potential to affect any patient whose care included auscultation of the lungs by Registered Respiratory Therapist (RRT) and blood sugar check in the Intensive Care Unit. Findings follow:

A. While observing a ventilator check and subsequent respiratory therapy treatment on Patient #7 at 1120 on 12/02/15, the RRT was observed to lay her clipboard on the bedside chair in the room. RRT then alcoholed her hands and donned gloves. RRT retrieved medications from her clipboard. RRT started the respiratory treatment, removed her gloves and re-gloved. RRT then manipulated the treatment tubing and re-entered her clipboard without removing or changing her gloves. RRT auscultated Patient #7's lungs with her stethoscope, placing it around her neck when she was finished. RRT exited the room without cleaning stethoscope or clipboard. RRT washed her hands at the nursing station. During an interview with RRT at 1135 on 12/02/15 she was asked if she had other patient's medications in her clipboard and she stated yes. She was asked if she had cleaned her stethoscope after auscultating Patient #7's lungs and she stated no.
B. While observing a fingerstick blood glucose at 1145 on 12/02/15 the Certified Nurse Aide (CNA) was observed to touch patient with gloved hands, pick up the glucometer to perform the fingerstick, then place the glucometer back in the glucometer case without cleaning it first.
C. During an interview with the Quality & Risk Director and Cardio-Pulmonary Director at 1200 on 12/02/15 they both verified the findings in B.


Based on policy and procedure review, document review and interview, it was determined the Facility failed to ensure the temperature and humidity levels in Operating Rooms (OR) # (number) 1-4 were maintained at levels determined by policy and procedure from 09/01/15 through 11/30/15. Failure to ensure the OR temperatures and humidity levels were held between 68 and 73 degrees and 50 and 60 percent respectively, had the potential to allow bacterial growth in the rooms and on any instruments stored in the rooms thus reducing infections. The failed process had the potential to affect any patient who underwent procedures in OR rooms#1-4 between 9/01/15 and 11/30/15. Findings follow:

A. Review of the policy and procedure titled TEMPERATURE AND HUMIDITY received from the Surgical Services Director on 12/01/15 revealed the following:
I. PURPOSE:
To provide an environmentally safe department.
II. POLICY:
A. The temperature of the operating room should be maintained between 68 degrees and 73 degrees F (Fahrenheit). The humidity should range between 50 % (percent) and 60%. B. The temperature and humidity will be monitored and recorded per computer by the Engineering Department.
C. Should the temperature and/or the humidity exceed the specified ranges engineering will notify the OR Department. Hand held gauges will be kept in each OR suite for periodic testing when indicated.
B. Review of the temperature and humidity record sheets received from the Physical Plant Director on 12/02/15 revealed readings performed three times a day by computer. Review of the temperature and humidity sheets from 09/01/15 through 11/30/15 revealed no documentation the temperature and humidity readings were within the ranges mandated by the Facility's policy and procedure: 68 - 73 degrees for temperature and 50 - 60 % for humidity. During an interview with the Physical Plant Director on 12/02/15 he verified the findings in B.
C. During an interview with the Surgical Services Director at 1050 on 12/03/15 he stated he checked temperature and humidity levels in all four OR rooms with a hand held gauge on 12/03/15 and there was discrepancies between the hand held readings and the computer readings.