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.

Based on interviews and record review, the facility failed to notify the family members of patients who were admitted to the hospital when requested in 1 of 5 emergency medical records reviewed (Patient #1).

The failure denied an incapacitated patient the ability to have an alternate decision-maker present during medical treatments.



According to the policy Informed Consent and General Consent for Treatment, in a medical emergency consent may be implied if the patient is incompetent; immediate treatment is needed to preserve life or prevent serious harm; and the physician reasonably believes to obtain consent from someone authorized to consent on the patient's behalf is not feasible and a reasonable person would consent in order to safeguard the welfare of the patient.

In these circumstances, documentation within the patient's medical record must support the presence of a medical emergency and must be signed by the physician. Continuous effort must be made to contact an alternate decision-maker.

1. The facility failed to ensure an alternate decision-maker was contacted or present during medical treatment on an incapacitated patient.

a. Review of the medical record of Patient #1 revealed s/he was brought to the facility by ambulance on 12/21/15 at 9:50 p.m. for a head injury sustained during a fall. The medical record of Patient #1 showed s/he was intoxicated. The General Consent for Treatment and Terms Relating to Payment ("Consent") form was not signed by the patient and a box was checked next to the statement "Patient refused to sign". The consent was signed and witnessed by two facility staff.

Further review of the medical record revealed the face sheet Next of Kin section was completed and identified the name, address and phone number of the patient's family member. There was no documentation in the medical record to show the facility attempted to contact the patients' next of kin.

b. In an interview with an emergency department (ED) Registered Nurse (RN #6) on 02/17/16 at 2:21 p.m., s/he stated when an intoxicated or incapacitated patient is admitted to the facility, s/he would document in the patient's medical record if the patient requested to have a family member called and when the call was made.

c. An interview was conducted with the ED Nurse Manager (Manager #8) on 02/17/16 at 3:26 p.m. Manager #8 stated when a patient is unable to give consent due to incapacitation, the facility will work to contact a family member at the patient's request. Manager #8 stated all ED staff had been re-trained to ensure attempts to contact family members of incompetent or incapacitated patients was completed and documented in the patient's medical record. Manager #8 further stated there was no documentation to show re-training of the ED staff had been completed.

d.. On 02/17/16 at 3:40 p.m., an interview was conducted with the Director of Emergency Services (Director #9). Director #9 stated the facility is obligated to provide care if it's clear the patient is not capable of making an informed decision. Director #9 further stated there should be documentation to show if any attempts are made to contact the patient's family member.

Patient #1 remained in the ED from 9:50 p.m. until 6:30 a.m. the next day. There was no documentation within the patient's medical record to show any attempt was made to contact a family member in the 8 hours Patient #1 was in the ED.
Based on observations, interviews, and document review the facility failed to provide safe handling and preparation of authorized medications.

This failure created the potential for patients to contract a healthcare acquired infection secondary to improper hand hygiene while handling and administrating medications.



The policy, Hand Hygiene for Infection Prevention, stated because contamination to hands occurs from patient contact as well as from contact with surfaces and equipment, [the facility] follows the World Health Organizations (WHO) 5 Moments for Hand Hygiene as the expectation for when hand hygiene will occur.


According to the WHO the 5 moments of hand hygiene included: before touching a patient; before clean/aseptic procedures including preparing food, medication, pharmaceutical products; after body fluid exposure/risk; after touching a patient; and after touching patient surroundings such as changing bed linen with the patient out of the bed and clearing a bedside table.

1. The facility failed to provide safe handling of medication to ensure protection of healthcare acquired infection.

a) On 02/16/16 at 9:49 a.m., a medication administration by RN #3 was observed. The medication was administered through a gastric tube, a tube inserted through the abdomen that delivers medication directly to the stomach RN #3 was observed wearing gloves while handling medication. RN #3 then cleaned the bedside table and disposed of trash from the floor with the same gloved hands. Without performing hand hygiene or changing gloves, s/he then prepared and administered the medication via the gastric tube. RN #3 did not perform hand hygiene after touching the patient surroundings or before touching the patient.

b) On 02/16/16 at 10:39 a.m., an interview was conducted with RN #2. S/he stated that anytime you touch a patient and then touch an inanimate object you need to change gloves before touching the patient again in order to maintain the WHO's 5 moments of hand hygiene and facility policy.

c) On 02/17/16 at 9:24 a.m., an interview with RN Manager #4 was conducted. S/he reiterated the facility followed the WHO's 5 moments of hand hygiene. RN Manager #4 stated s/he was disappointed RN #3 did not change gloves before administering medications through a gastric tube after RN #3 had touched the floor and discarded trash.

d) On 02/18/16 at 9:48 a.m., Manager #13 was interviewed. S/he stated it was the facilities expectation and policy to follow the World Health Organization's 5 moments of hand hygiene. RN #3 should have absolutely changed gloves and performed hand hygiene before administering the medication through a gastric tube. Manager #13 further stated hand hygiene should be as automatic as crossing the street.