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 Jan. 27, 2017
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on clinical record review, it was determined the Facility failed to ensure two (#9 and #12) of five (#1, #7, #9, #12, and #13) Medicare patients admitted to 2 East signed initial Medicare Important Notices in the clinical record. Based on clinical record review it was determined that patients did not have the Medicare Important Notice in the record at/prior to discharge. Failure to ensure issuance of the Medicare Important Notice did not allow the patients the opportunity to be informed of and aware of their rights as a hospital patient, as well as their discharge and appeal rights. The failed practice affected Patients #9 and #12. Findings follow:

A. Review of Patient #9 and Patient #12's clinical record revealed neither contained a signed Medicare Important Notice for admission or discharge.

B. During an interview with the Director of Quality/Risk Management at 1430 on 01/27/17 she verified the findings in A and stated all Medicare patients should have a signed Medicare Important Notice at admission.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on clinical record review and interview, it was determined the Facility failed to obtain consent for care on two (#9 and #12) of five (#1, #7, #9, #12 and #13) patients admitted to 2 East. Failure to obtain consent for care did not allow the patient or their representative to make a clear, informed and knowledgeable decision regarding their care. The failed practice affected Patients #9 and #12. Findings follow:

A. Review of the clinical records of Patient # 9 and #12 revealed an unsigned consent form.

B. During an interview with the Director of Quality/Risk Management at 1430 on 01/27/17 she verified the findings in A and stated all patients should have a signed consent in their clinical record.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on clinical record review, policy and procedure review and interview, it was determined the Facility failed to protect the personal privacy of one (#15) of five (#3-#5, #14 and #15) current Gero-Psychiatric patients in that the upper torso was exposed in photographs documenting a bump on the forehead. The failed practice did not afford the basic right of personal physical privacy to Patient #15. Findings follow:

A. During Patient #15's clinical record review, 6 of 20 pictures documenting a post-fall bump on the forehead revealed Patient #15's breasts were included in the pictures.

B. Review of the policy and procedure titled "Patient Photographs" received from the Director of Quality/Risk Management at 1550 on 01/27/17, did not reveal any declaration regarding protecting the patient's physical privacy.

C. During a group interview at 1100 on 01/27/17 with the Chief Nursing Officer, the Director of Quality/Risk Management and the Director of Gero-Psychiatric all three stated Patient #15's breasts should not have been exposed and included in the photograph view.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on policy and procedure review, clinical record review and interview, it was determined one of one (#2) patient was not restrained in accordance with a physician's order. Failure to obtain a physician's order for restraints did not allow the physician to be knowledgeable regarding the patient's need for restraints and prohibited the Facility from following its policy. The failed practice affected Patient #2. Findings follow:

A. Review of the policy and procedure titled "Restraint/Seclusion" received from the Director of Quality/Risk Management at 1100 on 01/23/17 revealed the following under III.POLICY: ...F. Restraint usage is via a physician's order; under VII. ORDERING: A ...Verbal orders for restraints must be co-signed within 24 hours. The physician must assess the patient at the time. Orders must be renewed at least every 24 hours. The physician must personally observe, evaluate and document the continued need for physical restraint every 24 hours...

B. Review of Patient #2's clinical record revealed he was in restraints from 1400 on 01/18/17 until 0730 on 01/23/17.

C. Review of restraint orders dated 01/18/17 at 1250, 01/18/17 at 1850, 01/19/17 at 1800, 01/20/17 at 1830, 01/21/17 at 0700 and 01/22/17 at 0700 revealed none of the orders were signed by a physician.

D. During an interview with the Director of Quality/Risk Management at 1340 on 01/27/17 she verified the findings in A, B and C.
VIOLATION: LICENSURE OF NURSING STAFF Tag No: A0394
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of personnel records, employee license verification, policy and procedure, job descriptions, schedules and interviews, it was determined the Facility failed to ensure 2 (#6 and #10) of 10 (#1-#10) Registered Nurses had a current license; and failed to ensure three (#6, #10 and ##11) of 12 employees met the licensure requirements as listed on their job description. The Facility could not assure staff were licensed and qualified. The failed practice was likely to affect any patient treated at the Facility. The findings were:

A. Employee #6, listed as a Registered Nurse on the employee roster provided on 01/26/17, had a hire date of 09/02/14. Review of the personnel file revealed a compact state license from Arizona and a due for renewal date of 04/01/17. The Director of Nursing was asked if Employee #6 was a resident of Arkansas. The Director of Nursing provided a copy of an Arkansas driver's license for Employee #6, issued 07/22/14. The Director of Nursing stated Employee #6 was still an active employee and he confirmed Employee #6 was a resident of Arkansas but did not have a Registered Nursing License for the State of Arkansas on 01/27/17.

B. Employee #10 was listed as a Registered Nurse on the employee roster provided on 01/26/17. Review of the employee license verification revealed a Registered Nurse license with an expiration Date of 11/30/16. The Director of Human Resources confirmed on 01/26/17 at 1105 the Registered Nursing License of Employee #10 was expired. Review of the schedule for nursing staff from 12/01/16 - 01/23/17 revealed Employee #10 was on the schedule as "House Charge" on the 7 p.m. shift for 6, 12 hours shifts from 01/09/17 through 01/12/17. Other duties assigned on the schedule included a part on the "code team" for "Meds/Defib". In an interview with the Chief Nursing Officer on 01/26/17 at 1612, it was confirmed Employee #10 had worked as a Registered Nurse in the Facility since her license expired on [DATE]. Review of the job description for the House Supervisor, also know as the "Resource Nurse", provided by the Chief Nursing Officer on 01/26/17 at 1520, revealed the primary function, "Under administration direction, is responsible for managing the human and material resources of the nursing departments in order to provide optimal patient care and satisfaction. Serves as a resource to hospital staff and physicians to facilitate quality and timely patient care." The job description lists the individual reports to the Chief Nursing Officer and the prerequisites are "Graduate of an approved program of nursing with a current license as a registered nurse in the state of Arkansas ...Current clinical nursing skills for provision of direct patient care as needed."

C. Employee #11 was identified by the Chief Nursing Officer as the Director of the Gero-Psychiatric Unit. Review of the personnel file on 01/24/17 revealed Employee #11 was not a Registered Nurse. The Education Background from an application of employment, completed on 01/04/16 was a Bachelor of Science with an emphasis in dietetics and a Master of Science with an emphasis in Dietetics. A copy of the Job Description for Employee #11 (Program Director) was provided by the Human Resources Director on 01/25/17 at 1110. The job description lists "reports to CEO"; prerequisites are "Bachelor's degree in Behavioral/Healthcare Sciences or a related field from an accredited College or University; Master's degree preferred. Experienced Geriatric Psychiatry RN (Registered Nurse). Minimum 3 years' experience in specialty area. Management/supervisory experience required." On 01/25/17 at 1242 by interview, the Chief Nursing Officer stated he was not aware Employee #11 had to be a Registered Nurse, according to the job description." The Nurse Manager of the Unit is a Registered Nurse and according to the Chief Nursing Officer on 01/27/17 at 1410 is responsible for the nursing care on the Unit and reports to him.

D. Review of the facility policy "Verification of Licensure/Certification/Registration" revealed "when law or regulations requires care providers to be currently licensed, certified or registered to practice their professions, the hospital both verifies these credentials with the primary source and documents this verification when a provider is hired and when his or her credentials are renewed. Verification of credentials may be done via secure electronic communication, facsimile or by telephone. Verification will be documented and kept on file in the Human Resources Department. Documentation will be obtained from the verifying organization and retained by the Human Resources Department." "Employees whose jobs require a license, certification or registration may not work if their credentials are expired and will be removed from the active schedule.

E. The findings in A - D were discussed with the Chief Nursing Officer and the findings as listed in A - D were confirmed on 01/27/17 at 1410.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on clinical record review and interview, it was determined a Registered Nurse failed to supervise and evaluate the care of 3 (#9, #11 and #15) of 15 (#1-15) patients in that neurological checks and vital signs were not obtained as ordered by the physician, warm moist heat treatments and Butt Paste was not administered as ordered by the physicians. Failure to perform neurological checks and obtain vital signs did not provide the physician with necessary information to make informed decisions related to the patients care and failure to administer warm moist heat treatments and Butt paste had the potential to allow further skin deterioration. The failed practice affected Patients #9, #11, and #15. Findings follow:

A. Review of Patient #9's clinical record revealed orders authored by Physician #1 at 2214 on 11/09/16 for neurological checks and vital signs taken every two hours. Review of the clinical record revealed no documentation of the neurological checks and vital signs performed every two hours from 11/01/16 through 11/14/16. The findings were verified by the Director of Quality/Risk Management at 1400 on 01/17/17.

B. Review of Patient #11's clinical record revealed an order authored by Physician #3 at 1500 on 12/08/16 for vital signs to be taken every shift (12 hour shifts) and an order authored by Physician #2 at 1515 on 12/21/16 for vital signs every four hours for 24 hours. Review of the clinical record revealed no documentation of vital signs performed every shift on 12/11/16, 12/13/16, and 12/17/16. Review of the clinical record revealed no documentation of vital signs every four hours. The findings were verified by the Director of Quality/Risk Management at 1415 on 01/27/17.

C. Review of Patient #15's clinical record revealed an order authored by Physician #3 on 12/23/16 for Butt Paste to be applied to buttocks, peri area and sacrum twice a day and an order authored by Physician #2 for warm, moist heat to be applied to the right lateral calf three times a day. Review of the Medication Administration Record revealed no documentation the Butt Paste was applied twice a day on 01/24/17 and no documentation the warm, moist heat was applied three times a day on 01/23/17 and 01/24/17. The findings were verified by the Director of Quality/Risk Management at 1040 on 01/27/17.
VIOLATION: RESPIRATORY SERVICES Tag No: A1163
Based on clinical record review and interview, it was determined three Respiratory Therapy treatments were administered to Patient #10 without a physician's order and one treatment was not administered per physician's order. Failure to follow physician's orders had the potential for the patient to suffer an adverse reaction, worsening of disease process and possibly prolonged hospitalization . The failed practice affected Patient #10. Findings follow:

Review of Patient #10's clinical record revealed the following in the physician's orders: "1621 on 12/12/16 Late entry for 12/11/16 0800 Douneb X (times) 1 T. O. (telephone order) Dr. (Physician #4)." Review of the clinical record revealed three Albuterol 2.5 mg (milligram) updraft treatments given on 12/10/16 at 0915 and 1550 by Registered Respiratory Therapist and one at 2015 by Certified Respiratory Therapist and no documentation the Douneb was given on 12/11/16. During an interview at 1450 on 01/27/17 the above findings were verified by the Director of Quality/Risk Management at 1450 on 01/27/17.