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.
| DECATUR COUNTY GENERAL HOSPITAL | 969 TENNESSEE AVE S PARSONS, TN 38363 | April 6, 2011 |
| VIOLATION: PATIENT RIGHTS | Tag No: A0115 | |
| Based on review of facility board minutes, facility policy, review of facility grievances and interview, it was determined the facility failed to protect and promote the rights of patients as evidenced by failure to ensure the grievance procedure was followed as set forth by the governing body and that patients/patient representatives were given written notice of the grievance investigation conducted by the hospital. The findings included: 1. The facility failed to follow the grievance procedure approved by the governing body delegating authority to the grievance committee to thoroughly investigate patient grievances. Refer to A0119 2. The facility failed to provide written notification to patients with grievances, including the steps taken on behalf of the patient and the results of the investigation. Refer to A0123 |
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| VIOLATION: PATIENT CARE ASSIGMENTS | Tag No: A0397 | |
| Intakes: TN 611 Based on observations, interviews and review of personnel records, it was determined the facility failed to ensure all staff providing nursing care under the supervision of a Registered Nurse (RN) were qualified to perform nursing duties. The findings included: Observations on 4/5/11 at 8:45 AM at the nursing desk in the post-operative area of the surgical unit revealed a paramedic was working in the area. In an interview at the time of the observation, the Paramedic stated her job duties in this area included checking vital signs, starting IV's [inserting intravenous cannulas] and anything she was asked to do within her scope of practice. In an interview on 4/5/11 at 1:45 PM in the ambulance bay, an Emergency Medical Technician trained for Intravenous infusion (EMT-IV) stated the paramedics and EMTs who work with the hospital's Emergency Medical Service are called to the hospital to assist with lifting heavy patients or "when they have trouble starting IV's." He stated they may be called more than once a shift, or not called for several days, "Basically, we were told since the ambulance service is owned by the hospital, we are to go help when they need us; nothing outside our scope of practice." In an interview on 4/5/11 at 9:00 AM in the conference room, the Director of Nursing (DON) stated Paramedics are used to come start IV's in the hospital if nursing is unable to get an IV started, respond to codes in the emergency room , respond to assist with violent patients and sit with suicidal patients. She stated, "They are not allowed to touch patients, they know what's in their code of conduct and they tell us what they are and are not allowed to do." She further stated there is one paramedic that works in the ER as needed and occasionally works in surgery. Review of the job description for the paramedic observed working in the post-op area revealed, "JOB TITLE: ER [emergency room ] Paramedic, DEPARTMENT: Nursing, SUPERVISOR: Nursing Supervisor/Nurse Executive... POSITION SUMMARY: ...The ER Paramedic may provide routine care in accordance with the established policies and procedures of [named hospital] and as directed by the Nurse Supervisor, Nurse Executive and Paramedic to assure the highest degree of quality patient care is given and maintained at all times... SCOPE OF RESPONSIBILITY: To assist in direct patient care under the supervision and direction of a R.N. ... IMPORTANT: This job description is not intended to be all-inclusive; an employee will also perform other reasonably related job responsibilities as assigned by immediate supervisor and other management as required. This organization reserves the right to revise or change job duties as the need arises..." |
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| VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES | Tag No: A0749 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Precision XceedPro Operator's Guide, facility policy, observation and interviews, it was determined the facility failed to ensure measures to prevent the potential spread of infection were in place as evidenced by not adopting accepted standards of practice for cleaning and disinfecting blood glucose meters (glucometers) for 3 of 3 days of the survey. The findings included: 1. Review of Precision XceedPro operator's guide documented: "...Cleaning the exterior surface of the Precision XceedPro Monitor daily is recommended. Follow your facility's policies and procedures for infection control..." 2. Review of the facility's Blood Glucose Monitoring policy revealed, "...when daily controls are performed, the meter will be inspected and cleaned with a germicidal solution. Acceptable cleaning solutions include alcohol and ammonia based cleaners..." 3. Observation in Patient #5's room on 4/5/11 at 4:35 PM, revealed Nurse #1 did not clean the port protector after the glucometer was used. During an interview at the nursing station with the charge nurse on 4/5/11 at 10:30 AM, the charge nurse stated, "...glucometers are cleaned with alcohol and documented daily on a log when cleaned..." During an interview in the conference room on 4/6/11 at 2:30 PM, the DON verified the above findings. 4. During an interview in the emergency room on [DATE] at 9:22 AM during initial tour of the facility, Nurse #2 stated the outside of the glucometer is cleaned after each use with alcohol swabs, "but not that part up there," pointing to the test strip port. She further stated, "We can take that part out and change it out so we could clean it. The lab [laboratory staff] comes and cleans that part. It gets cleaned every shift..." During an interview in the lab on 4/6/11 at 9:00 AM, Lab Technician #1 stated, "...glucometers are cleaned daily by nurses or whoever uses them..." 5. The facility policy provided to the surveyors failed indicate the source the was used to develop the facility ' s policy besides the manufacturer's recommendations/training manual and "Clinical Diagnosis and Management by Laboratory Methods" manual. |
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| VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES | Tag No: A0119 | |
| Based on review of Board Trustee's minutes, facility's grievance policy and interview, it was determined the facility failed to follow the grievance process approved by the governing board delegating the effective operation of the grievance process to the grievance committee. The findings included: 1. Review of the Decatur County General Hospital Monthly Board of Trustees Meeting dated March 3, 2008 at 6:30 PM, documented on page 4, "4. A Complaint & Grievance Policy was reviewed. This is required by CMS and changes to our current policy were made to be consistent with CMS regulations..." 2. Review of the facility policy, "Complaint and Grievance Policy" documented, "...The Quality Assurance Department is responsible for the effective operation of the grievance process and for conducting and/or coordinating the review and resolution of grievances, except for those grievances relative to billing issues...Grievance: Complaints, which are not promptly resolved by staff present...Written Response: A response to a grievance issued on official [HOSPITAL NAME] letterhead, after approval by the Risk Management and Quality Assurance Departments...Specific Information: Grievance Process: [hospital] convenes an ad hoc committee to handle each grievance...The grievance committee reviews/investigates/ analyzes each grievance in order to determine the most appropriate resolution ...However, in all case the hospital provides a written response to each patient's grievance ...A grievance is considered resolved when the patient is satisfied with the actions taken on their behalf or when the hospital has taken appropriate and reasonable actions on the patient's behalf in order to resolve the patient's grievance..." 3. Review of 14 grievances from 11/12/10 through 1/6/11, documented all 14 as complaints. None of the grievances documented when the item was discussed by the committee. There was no documentation of how and when the grievances were investigated or the resolution of the grievances. 4. During an interview in the conference room on 4/5/11 at 2:15 PM, the Patient Advocate/ LPN (PA) was asked who served as the complaint review committee. The PA stated, "The CEO and [named Chief of Staff]...I'm not sure who they have in there. I give a copy (of the complaint) to them, they bring them back to me...I bring them to QA [Quality Assurance]..." When asked how the patients/families were notified of the results, the PA stated, "If they request a phone call, I call them back." When asked the difference in a complaint and a grievance, the PA stated, "I haven't had a grievance." The PA stated, "[grievance is] something with no resolution, if you don't feel it's resolved." When asked how concerns with particular physicians' were addressed, the PA stated, "I think the info about doctors is something the Chief of Staff and the Administrator [CEO] take back to [named Emergency Services contractor], but I don't know." 5. During an interview on 4/5/11 at 2:45 PM, the Joint Commission Coordinator (JCC) stated, "I don't know who is on the [grievance] committee...I would say the CEO and Chief of Staff are the committee ...if [PA] has something that she feels like is a grievance, the CEO or Chief of Staff looked at it and said treatment was or was not appropriate, based on their response, QA might look at it...QA meets on Thursday and I don't work on Thursday...PA gives a report in QA of the complaints, the Chief Executive Officer [CEO] and Chief of Staff keep [them]on file..." 6. During an interview on 4/6/11 at 1:15 PM, the CEO stated, "myself, [named PA] and [named Chief of Staff] are on the committee." When asked if the committee met together, the CEO stated, "If all three of us are available." When asked the last time the committee members met to discuss grievances, the CEO stated, "Last time most likely was at the QA meeting when the three of us were at the same place...there is no focused grievance committee..." |
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| VIOLATION: PATIENT CARE ASSIGMENTS | Tag No: A0397 | |
| Based on observations, interviews and review of personnel records, it was determined the facility failed to ensure all staff providing nursing care under the supervision of a Registered Nurse (RN) were qualifiedand competent to perform nursing duties. The findings included: 1. Observations on 4/5/11 at 8:45 AM, at the nursing desk in the post-operative area of the surgical unit, revealed a paramedic working in the area. During an interview at the time of the observation, the Paramedic stated her job duties in this area included checking vital signs, starting IV's [inserting intravenous cannulas] and anything she was asked to do within her scope of practice. 2. During an interview on 4/5/11 at 1:45 PM in the ambulance bay, an Emergency Medical Technician trained for Intravenous infusion (EMT-IV) stated the paramedics and EMTs who work with the hospital's Emergency Medical Service were called to the hospital to assist with lifting heavy patients or "when they have trouble starting IVs." He stated they may be called more than once a shift, or not called for several days, "Basically, we were told since the ambulance service is owned by the hospital, we are to go help when they need us; nothing is outside our scope of practice." 3. During an interview on 4/5/11 at 9:00 AM in the conference room, the Director of Nursing (DON) stated Paramedics were used to start IVs in the hospital if nursing was unable to get an IV started, [they] responded to codes in the emergency room , and to assist with violent patients, sitting with suicidal patients. She stated, "They are not allowed to touch patients, they know what's in their code of conduct and they tell us what they are and are not allowed to do." She further stated there is one paramedic that works in the ER as needed and occasionally worked in surgery. 4. Review of the job description, for the paramedic observed working in the post-op area revealed, "JOB TITLE: ER [emergency room ] Paramedic, DEPARTMENT: Nursing, SUPERVISOR: Nursing Supervisor/Nurse Executive... POSITION SUMMARY: ...The ER Paramedic may provide routine care in accordance with the established policies and procedures of [named hospital] and as directed by the Nurse Supervisor, Nurse Executive and... SCOPE OF RESPONSIBILITY: To assist in direct patient care under the supervision and direction of a R.N... IMPORTANT: This job description is not intended to be all-inclusive; an employee will also perform other reasonably related job responsibilities as assigned by immediate supervisor and other management as required..." |
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| VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION | Tag No: A0123 | |
| Based on review of facility board minutes, facility policy, review of facility grievances and interview, it was determined the facility failed to provide patients with written notification for 14 of 14 grievances reviewed. The findings included: 1. Review of the Decatur County General Hospital Monthly Board of Trustees Meeting dated March 3, 2008 at 6:30 PM, documented on page 4, "4. A Complaint & Grievance Policy was reviewed. This is required by CMS and changes to our current policy were made to be consistent with CMS regulations..." 2. Review of the facility policy, "Complaint and Grievance Policy" documented, "..Written Response A response to a grievance issued on official [Hospital] letterhead, after approval by the Risk Management and Quality Assurance Departments...However, in all case the hospital provides a written response to each patient's grievance that includes the following: The name of the hospital contact person; The steps taken to investigate the grievance; The results of the grievance process; The date of completion (usually the date of the letter)...A grievance is considered resolved when the patient is satisfied with the actions taken on their behalf or when the hospital has taken appropriate and reasonable actions on the patient's behalf in order to resolve the patient's grievance, even though the patient or the patient's representative remains unsatisfied with the hospitals actions..." 3. Review of 14 grievances dated from 11/12/10 through 1/6/11, did not have a written response issued to the patient or patient representative. Documentation of the grievances failed to reflect when the investigation occurred or when the investigation was completed. 4. During an interview in the conference room on 4/5/11 at 2:15 PM, the Patient Advocate/ LPN ( PA) was asked how the patients/families were notified of the investigation results. The PA stated, "If they request a phone call, I call them back." The PA verified she did not send, nor had she ever sent written notification after a grievance was reviewed. |
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| VIOLATION: PHYSICAL ENVIRONMENT | Tag No: A0700 | |
| Based on observation and record review, it was determined the facility failed to arrange and maintain the hospital to ensure the safety of all patients. The findings included: 1. The facility failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner to ensure the safety and well being of the patients. Refer to A 701 2. The facility failed to ensure the life safety requirements for the hospital were met. Refer to A 709 |
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| VIOLATION: MAINTENANCE OF PHYSICAL PLANT | Tag No: A0701 | |
| Based on observation and record review, the facility failed to ensure the condition of the physical plant and overall hospital environment were maintained in a manner to ensure the safety and well being of patients. The findings included: 1. The electrical wiring and equipment was not in accordance with NFPA 70, National Electrical Code. Refer to K 147 2. The emergency generator sets were not in accordance with NFPA 99, Chapter 3. Refer to K 144 |
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| VIOLATION: LIFE SAFETY FROM FIRE | Tag No: A0709 | |
| Based on observation, it was determined the hospital failed to meet all fire safety requirements for the entire building. The findings included: 1. The facility failed to provide a construction type with a complete automatic sprinkler system throughout in accordance with NFPA 13. Refer to K 12 2. The facility failed to maintain all fire extinguishers in accordance with NFPA 10. Refer to K 64 |
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