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 Nov. 7, 2018
VIOLATION: INSTITUTIONAL PLAN AND BUDGET Tag No: A0077
Based on interview it was determined the facility failed to ensure the budget was prepared with the participation of the governing body, medical staff, and administrative staff. The failed practice did not ensure leadership was knowledgeable regarding the contents of the budget and expenditures. The failed practice created the potential for available funds to be prematurely exhausted due to a lack of knowledge of the amount of available funds, which had the likelihood to negatively impact patient care. Findings follow.

During an interview on 11/07/18 at 7:45 AM, the Chief Executive Officer confirmed the facility did not have a current operating budget.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview it was determined the Governing Body failed to 1) Have a current operating budget in place. See A-0073; 2) Submit a budget for review by a planning agency. See A-0074; 3) Review and update the budget annually. See A-0076; and 4) Prepare a budget with the participation of the Governing Body. The failed practices did not ensure the Governing Body would be able to oversee the actions of the facility's leadership to ensure expenditures did not overextend the available funds, which had the likelihood to negatively impact patient care.
VIOLATION: INSTITUTIONAL PLAN AND BUDGET Tag No: A0073
Based on interview, it was determined the facility failed to have a current operating budget in place. The failed practice did not ensure funds were available to meet the operational needs of the hospital and created the likelihood for insufficient funds due to a lack of knowledge of anticipated income and expenses, which had the likelihood to negatively impact patient care. Findings follow.

During an interview on 11/07/18 at 7:45 AM, the Chief Executive Officer confirmed the facility did not have a current operating budget.
VIOLATION: INSTITUTIONAL PLAN AND BUDGET Tag No: A0074
Based on interview it was determined the facility failed to submit a capital expenditure plan to a planning agency for review. The failed practice did not ensure the planning agency would be able to oversee the actions of the facility's leadership to ensure expenditures did not overextend the available funds. The failed practice created the potential to prematurely exhaust available funding, which had the likelihood to negatively impact patient care. Findings follow.

During an interview on 11/07/18 at 7:45 AM, the CEO stated the facility did not have a capital expenditure plan, thus no plan was submitted to a planning agency.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on Medical Staff Rules and Regulations, clinical record review and interview, it was determined the facility failed to assure Emergency Department (ED) physician's orders for discharge were signed and dated for 14 (#12 through #20, and #23 through #27) of 16 ( #12-#27) ED patients and physician's orders for admission, diagnostic studies, and medications were dated and timed for 5 (#13, #14, #16, #22 and #24) of 16 (#12-#27) ED patients. Failure to sign, date, and time physician's orders did not ensure medical staff were following the facility Rules and Regulations and did not ensure staff knew the time frame for the orders. The failed practice had the potential to affect Patients #12 through #20 and #22 through #27. Findings follow:

A. Review of the Medical Staff Rules and Regulations received on 11/08/18 showed all clinical entries in the patient's medical record were to be accurately dated, timed, and authenticated.

B. Review of the discharge orders for Patients #12 through #20 and #23 through #27 did not show a dated signature.

C. Review of the ED orders for Patient #13, #14, #16, #22 and #24 showed ER orders for admission, diagnostic studies, and medications were not dated or timed.

D. During an interview with the Chief Nursing Officer at 2:25 PM on 11/07/18 the findings in B and C were verified.





Based on policy review, review of Crash Cart Check Records, and interview, it was determined the facility failed to ensure three of three (Trauma #1, Trauma #2, and Cardiac) crash carts were checked every shift. Failure to check crash carts every shift did not ensure all components of the crash cart were in working order in the event of an emergency and had the likelihood to affect any patient needing services involving the crash cart. Findings follow.

A. Review of policy titled, "Crash Carts - Inspection, Maintenance, and Exchange" showed, "The crash cart shall be checked each shift by licensed nursing personnel to: a) Verify the integrity of the locks. b) Assure that all equipment on the top and sides of the crash cart is available. c) Assure functioning of monitor/defibrillator."
B. Review of Crash Cart Check Records for 06/01/18 through 11/04/18 showed the following:
1) Trauma #1 was not checked for 48 shifts.
2) Trauma #2 was not checked for 46 shifts.
3) Cardiac was not checked for 34 shifts.
C. During an interview on 11/05/18 at 10:00 AM, the emergency room Manager confirmed the crash cart checks had not been done.
VIOLATION: INSTITUTIONAL PLAN AND BUDGET Tag No: A0076
Based on interview it was determined the facility failed to ensure the capital expenditure plan and budget were updated annually. The failed practice did not ensure all forecasting for income and expenses were up to date and reflective of current practices and processes of the facility and created the potential to prematurely exhaust available funding. Findings follow.

During an interview on 11/07/18 at 7:45 AM the Chief Executive Officer confirmed the facility did not have a budget and capital expenditure plan, thus it was not updated annually.
VIOLATION: LICENSURE OF NURSING STAFF Tag No: A0394
Based on personnel file review, nursing schedule review, policy and procedure review and interview, it was determined the facility failed to ensure that one of one Advanced Practice Registered Nurse (APRN) had a current nursing license. Failure to ensure APRN was working under a current nursing license did not ensure that patients received care from licensed practitioners. The failed practice had the potential to affect all patients the APRN provided care to from 08/01/18 through 11/07/18. Findings follow:

A. Review of the APRN's personnel file received on 11/07/18 showed an expiration date of 07/31/18 for both the Registered Nurse (RN) license and the APRN license.

B. Review of the Nursing Schedule received on 11/06/18 from the Chief Nursing Officer (CNO) showed the APRN worked on 10/15/18 - 10/17/18, 10/20/18 - 10/22/18, 10/25/18 - 10/26/18, 10/29/18 - 10/31/18, 11/03/18, and 11/05/18.

C. Review of the policy and procedure titled "Verification of Licensure/Certification/Registration" received from the CNO at 11:00 AM on 11/05/18 showed the hospital verified staff licensure/certification/registration on hire and during the course of employment, and that 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.

D. During an interview with the Chief Executive Officer at 9:05 AM on 11/07/18 he verified the personnel file did not contain a current APRN or RN license.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on policy and procedure review, clinical record review, and interview, it was determined the facility failed to ensure a Registered Nurse (RN) assessed one (#21) of 16 (#12 - 27) emergency room patients. Failure to ensure Patient #21 was assessed by a RN did not ensure the patient's health status/condition, needs and problems were identified and treated. The failed practice affected Patient #21. Findings follow:

A. Review of the policy and procedure titled "Nursing Assessment," received from the Chief Nursing Officer (CNO) at 12:30 PM on 11/05/18 showed a RN was to assess the patient's need for nursing care in all settings where nursing care was provided.

B. Review of Patient #21's clinical record showed there was no assessment completed by a RN.

C. During an interview with the ER Nurse Manager at 2:00 PM on 11/06/18 the findings in A and B were verified.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on review of policy and procedure, physician's orders, multidisciplinary care plans, and interview, it was determined the facility failed to ensure the physician specified the type of group therapy for 3 (#5, #7 and #11) of 11 (#1-11) patients and the frequency of group therapy sessions for 9 (#2-#8, #10 and #11) of 11 (#1-11) Gero/Psych (Geriatric/Psychiatric) patients. Failure of the physician to specify the type and the frequency of the group sessions did not ensure the therapy was individualized to each patient and did not provide guidance to the disciplines responsible for providing the therapy. The failed practice affected Patients #2-8, #10 and #11. Findings follow:

A. Review of the policy and procedure titled "Behavior Therapy," received from the Gero/Psych Nurse Manager at 9:30 AM on 11/06/18 showed behavior therapies were classified into two major groups: group program and individual therapies. Review of the policy and procedure showed "group strategies were uniformly applied to all geropsychiatric patients" and did not show a set or individualized frequency of each group.

B. Review of the standardized physician's Transitions Admissions Orders showed three groups listed on the order sheet: Memory, Reality and Serenity. Review of the orders for Patients #5, #7 and #11 showed no orders for group therapy. Review of the Daily Monitoring Sheets showed Patient #5, #7 and #11 in group therapy. Examples included; Patient #5 in group from 9:15 AM to 10:30 AM on 11/5/18, 1:30 PM to 3:15 PM on 11/5/18, 8:30 AM to 10:15 AM on 11/02/18, 2:30 PM to 3:15 PM on 11/02/18, 8:45 AM to 10:00 AM on 11/01/18, and 1:30 PM to 3:15 PM on 11/01/18.

C. Review of the Multidisciplinary Care Plans for 9 (#2-#8, #10 and #11) of 11 (#1-11) patients showed no specific group and no frequency listed for group therapy. Examples included: review of Patient #2's Multidisciplinary Care Plan did not show a specific named group that correlated with the orders; the care plan stated "individual" and "group" therapy, not "Memory, Reality or Serenity," and did not contain a frequency for the group.

D. During an interview with the Chief Nursing Officer at 2:20 PM on 11/07/18 the findings in A, B and C were verified.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation and interview, it was determined the facility failed to ensure patients in three of three areas toured (Emergency Department (ED), Intensive Care Unit (ICU), and Geriatric/Psychiatric [Gero/Psych] Unit) received care in a safe setting in that expired supplies were available for patient use, and personal care items were accessible to Gero/Psych patients. The failed practice had the potential to allow expired supplies to be used in patient care and personal care items to be used in a manner hazardous to humans. The failed practice had the potential to affect patients in the Emergency Department and on the Gero/Psych Units. Findings follow.

A. A tour was conducted of the Emergency Department (ED) and ICU (Intensive Care Unit) on 11/05/18 at 9:45 AM. The following items were observed:
1) Trauma Room - 35 of 35 purple top vacutainer tubes with an expiration date of 09/30/18, and 3 of 10 blue top vacutainer tubes with an expiration date of 09/30/18. During an interview on 11/05/18 at 9:55 AM, the Chief Executive Officer verified the above findings.
2) Equipment Room - 2 of 2 gray top vacutainer tubes with an expiration date of 09/30/18, 1 of 4 dark purple top vacutainer tube with an expiration date of 10/31/18, and 3 of 4 light purple top vacutainer tubes with an expiration date of 09/30/18. During an interview on 11/05/18 at 10:12 AM the ER Manager verified the above findings.
3) ICU - 104 of 104 blue top vacutainer tubes with an expiration date of 09/30/18. During an interview on 11/05/18 at 10:20AM, the ED Manager verified the above findings.
B. A tour was conducted of the Gero/Psych Unit on 11/05/18 at 10:30 AM. Observation under the sink in the Dayroom showed a plastic bag containing 19 adult diapers and a plastic bag containing 16 green chux; in the same cabinet the second drawer contained 2-7 ounce (oz) tubes of Sooth and Cool Barrier, 2-7 oz tubes of Soothe and Cool Skin Cream, 2-2 oz bottles of Medline Lotion, 1-4 oz bottle of mouthwash, and 1-0.85 oz tube of Colgate toothpaste. During an interview with the CEO at 10:45 AM on 11/05/18 the above findings were verified.
VIOLATION: ADEQUATE RESPIRATORY CARE STAFFING Tag No: A1154
Based on review of job descriptions, licenses, Cardiopulmonary Resuscitation (CPR) cards, work schedules and interview, it was determined the facility failed to ensure one (#8) of eight (#1-8) Respiratory Therapists had a current license and one (#3) of eight (#1-8) Respiratory Therapists had a current CPR card. Failure to ensure Respiratory Therapists were working under a current license and possessed a current CPR card did not ensure patients received care from licensed and competent personnel. The failed practice had the potential to affect all patients whose care was rendered by Respiratory Therapist #8 since 09/01/18 and Respiratory Therapist #3 since 05/31/18. Findings follow:

A. Review of the Respiratory Therapy job descriptions received from the Chief Executive Officer (CEO) at 9:20 AM on 11/07/18, showed each Respiratory Therapist was to have a current Arkansas State license and be currently certified in CPR.

B. Review of Respiratory Therapist #8's license received from the CEO at 8:00 AM on 11/07/18 showed it expired 08/31/18.

C. Review of Respiratory Therapist #3's CPR card received from the CEO at 8:00 AM on 11/07/18 showed it expired 05/31/18.

D. Review of the Respiratory Therapist work schedule from 09/16/18 through 10/13/18 and from 10/14/18 through 11/10/18, received from the CEO at 8:00 AM on 11/07/18, showed Respiratory Therapist #8 worked 9/17/18, 9/18/18, 09/21/18 through 09/23/18, 10/05/18 through 10/08/18, 10/10/18, 10/12/18 through 10/14/18, 10/16/18, 10/19/18 through 10/21/18, 10/23/18, 10/26/18 through 10/28/18, 11/01/18 through 11/04/18.

E. Review of the Respiratory Therapist work schedule from 09/16/18 through 10/13/18 and from 10/14/18 through 11/10/18, received from the CEO at 8:00 AM on 11/07/18, showed Respiratory Therapist #3 worked 09/19/18, 10/08/18, 10/15/18, 10/31/18 and 11/05/18.

F. During an interview with the Chief Nursing Officer at 1:45 PM on 11/07/18, the findings in A, B, C, D and E were verified.