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 medical record review, staff interview, observation, review of facility policies, contracts, staffing schedule and matrix, the hospital's governing body failed to ensure that the Quality program reflects the complexity of the hospital's organization and services.

Findings include:

Cross reference

0392 Staffing and Delivery of Care
0405 Administration of Drugs
0701 Maintenance of Physical Plant
Based on review of nurse's staffing schedule and staffing matrix, the facility failed to have adequate personnel to provide nursing care to all patients as needed.

Findings include:

Review of three (3) weeks of Nurse's staffing schedule (42 shifts) and staffing matrix for 8 Tour revealed:
Eleven (11) shifts were short staffed as follows:

2/7/16, AM shift (short 1 RN and 1 PCA)
2/8/16, AM shift (short 1 PCA)
4/10/16, AM shift (short 1 PCA)
4/11/16, PM shift (short 1 PCA)
4/13/16, PM shift (short 1 PCA)
4/15/16, PM shift (short 1 RN and 1 PCA)
4/16/16, AM and PM shifts (short 1 RN and 1 PCA)

Review of six (6) employee files revealed that all contained initial applications with references, job descriptions, had received annual trainings which included infection control, patient rights, and abuse/assault/neglect; had underwent competency testing and evaluations; and, had current BLS and ACLS certification, as appropriate.

Based on medical record review, review of facility policies, review of Nurse's staffing schedule, and review of employee files, the facility's nurses failed to administer medications as directed by the physician order.

Findings include:

Review of ten (10) medical records revealed that two (2- #s 4 and 5) patients had not received at least one (1) medication as ordered by the physician, as follows:

Review of patient #4's medical record revealed the [AGE] year old was admitted on [DATE] at 1:48 PM with diagnosis of Obesity, gout, sepsis, new onset of a-fib, and CHF.
Medical record contained evidence that Patient rights information had been provided
Consent for Treatment had been signed on 12/30/15 at 5:01 AM
The patient did have an indwelling urinary catheter (foley)
Review of MD orders revealed:
cardiac monitoring, pulse ox, bedrest, turn every two hours
Meropenem (antibiotic) 1 gm intravenously every eight (8) hours, start at 12/31/15 at 12:00 PM
Review of the Medication Administration Record revealed that Meropenem had been given:
12/31/15: 12:17 AM, 11:23 PM***
1/1/16: 8:00 AM- not done, missing dose, 11:22 AM***, 8:28 PM
1/2/16: 5:08 AM, 2:32 PM***, 8:39 PM
1/3/16: 4:53 AM, 12:51 AM
***indicates early or late medication administration
Rocephin (antibiotic) 1 gm intravenously every twenty-four (24) hours, start at 12/30/15 at 5:00 PM, stop date 12/30/15 at 5:48 PM
Review of the Medication Administration Record revealed that Rocephin had been given as ordered 12/30/15: 6:18 PM
Review of the Discharge Summary revealed the final diagnosis was Obesity, gout, sepsis, new onset a-fib, CHF, CAD, high lipids, and chronic kidney disease.
The patient was transported to Emory Against Medical Advice (AMA) on 1/3/16 at 5:08 PM by EMS with IV and foley intact (family refused to have removed). The patient was alert and oriented to person and place, interm confusion. MD aware. An AMA form was signed 1/3/16 at 2:30 PM by a sister.

Patient # 5, a 48 year old, was admitted on [DATE] with diagnosis of Crohns disease, seizure, high blood pressure, pneumonia, and sepsis.
MD orders included:
Zosyn 3.375 gm intravenously every six (6) hours, start at 4/10/16 at 3:00 PM
Zosyn 3.375 gm intravenously every eight (8) hours, start at 4/11/16 at 4:00 PM
Review of the Medication Administration Record revealed that Zosyn had been given:
4/10/16: 9:53 PM
4/11/16: 3:44 AM, 9:21 AM, 6:17 PM
4/12/16: 12:03 AM**, 8:42 AM, 4:16 PM
4/13/16: 1:09 AM, 8:10 AM (no 4 PM dose***)
4/14/16: (no midnight dose), 3:34 AM***, 11:58 AM, (no 8 PM dose), 10:32 PM***
4/15/16: 5:44 AM, 12:00 PM-not done, patient sleeping***, 8:53 PM***
4/16/16: 4:44 AM, 1:06 PM, 10:04 PM
4/17/16: 7:47 AM, 1:20 PM***- went to standard administration times, 10:39 PM
4/18/16: 7:32 AM, 3:45 PM, 10:14 PM- went to standard administration times
4/19/16: 4:47 AM, 5:27 PM***, 9:03 PM***
4/20/16: 4:47 AM, 2:19 PM, 9:12 PM
4/21/16: 5:12 AM, 1:40 PM, 10:08 PM
4/22/16: 3:39 AM***-early/late reason-went to standard admin times, (12:00 PM*** not done- equipment/supplies unavailable), 9:53 PM***
4/23/16: 4:08 AM, 11:10 AM, 8:23 PM
4/24/16: 5:16 AM, 2:44 PM, 9:16 PM
4/25/16: 3:49 AM, 11:12 AM, 9:07 PM
4/26/16: 5:19 AM, 2:16 PM, 10:27 PM
4/27/16: 5:28 AM, 4:02 PM**,
*** indicate early or late administration
Care plan: included infection
The patient was discharged stable to home: 4/27/16 at 6:45 PM

Review of facility policy #AMC-TX.320, Medication Order- Writing/Entry General Guidelines for the Patient's Electronic Medical Record (EMR), effective date January 2003, revision date June 2015, revealed:
Scheduled medication orders indicated a medication, dose, and route to be administered at a specific time interval or frequency
Medication orders were entered into the electronic medical record by prescribers or authorized personnel
Orders were verified by the Pharmacist, after review of appropriateness, dosing, completeness, formulary management, etc.

Review of six (6) employee files revealed that all contained initial applications with references, job descriptions, had received annual trainings which included infection control, patient rights, and abuse/assault/neglect; had underwent competency testing and evaluations; and, had current BLS and ACLS certification, as appropriate.
Based on observation, staff interview, review of Local Service Level Agreement Housekeeping Services and Environmental Services Manuals, the hospital failed to be maintained in a manner that ensured the safety and well-being of patients.

Findings include:

Observation on a 4/26/16 Tour at 12:25 PM with the CNO (Chief Nursing Officer), COO (Chief Operating Officer) , and the President revealed:
3 East, 11 rooms observed (#367, 369, 373, 375, 377, 379, 385, 386, 389, 390, and 391).
Rooms 377 and 385 with dirty floors
Room 385 with stained ceiling tiles
Rooms 377 and 389 with wall damage
Room 385 with sharps container full to opening
8 Tour, 13 rooms observed (#s 837, 839, 840, 845, 847, 857, 859, 860, 861, 863, 864, 869, and 870).
Rooms 837, 839, 845, 860, 863, and 864 with dirty floors
Room 870 with stained ceiling tile
Rooms 839 840, and 860, with wall damage
Room 860 with seven broken floor tiles
4/27/16 Tour of 4 Tour at 8:00 AM with the CNO revealed:
7 rooms observed (#s 432, 437, 473, 474, 476, 477, and 479)
Room 432 wall damage
Rooms 432 and 437 with dirty floors

Interview with employee #7 on 4/27/16 at 8:37 AM revealed that he/she had worked in environmental services for sixteen (16) months on day shift. He/she explained that the AM procedure for patient rooms was to empty the trash and check the room for needs. After all rooms had an initial check, staff would then return for cleaning. He/she continued on stating that staff used a neutralizing floor cleaner diluted with water in a bucket. Washable mop heads were placed in the solution, which was then used to mop room floors. A fresh mop head was used for each room. If there was a specific area of soiling, staff used A-456 on it. Corners and edges could be cleaned with a putty knife and/or brillo pad.

Interview with the Director of Environmental Services on 4/27/16 at 1:14 PM, revealed that he/she had worked by contracted service in the current position since July 2015. The director stated that staff were trained on hire and annually. The director also stated that services were contracted to clean rooms daily between 7:00 AM- 3:30 PM; and, that staff was available at other times to clean discharged patient rooms, or as needed. He/she went on explaining that staff swept rooms first, then wet mopped rooms with a microfiber mop, including corners and edges. The director also stated that staff should use brushes and/or a putty knife to clean corners and edges. He/she also stated that staffing was lighter on weekends and holidays; and, that a manager is on duty daily.

The director explained that he/she was responsible for all employees, had three (3) managers who covered different areas, and, that he/she and the managers conducted supervisory rounds daily. He/she went on stating that most of the rooms checked, were empty rooms. The director also stated that each manager conducted five (5) or six (6) satisfaction surveys daily, during which time, they also visualized the room's condition.

Supervisory rounds were documented on a form using an I-Pad. The form included a section to note if the floor needed regular maintanence or "project work". Supervisory rounding information was summarized, and the goal was to have at least an 85% or greater positive scores. If results were less than 85%, weekly training was conducted with all staff.

Interview with the 4 Tower Director on 4/27/16 at 2:32 PM revealed that he/she had been the director since May 2015, and usually worked 8:00 AM- 5:00 PM. The director stated that he/she had received complaints regarding the trash and floors being dirty in the past, and had phoned the environmental services supervisor to have the issues resolved, which they had each time.

Review of Local Service Level Agreement Housekeeping Services, Attachment 2, Inpatient Areas, revealed that the following services were provided seven (7) days per week:
Interact with patient and organize room
Spot clean
Clean and sanitize washrooms and bathrooms
Empty and clean waste receptacles
Damp clean floors
Spot clean floors
Two days per week:
Polish floors

Review of Sodexo Environmental Services Manuals and Videos, last updated 9/28/15, Chapter 1, Shine- Occupied Patient Room- Daily Cleaning, revealed that the cleaning process included:
Pull trash and linen
Complete the High Dust Process
Damp wipe all contact surfaces
Thoroughly clean the restroom
Dust mop properly
Damp mop all appropriate areas
Inspect the work according to the Shine standards