HospitalInspections.org

Based on review of the Quality Improvement documentation and interviews, it was determined:

1) The facility failed to implement a Quality Improvement Plan to include quality indicators and collection of data.

2) The facility failed to initiate Performance Improvement Projects.

3) The facility failed to identify areas for improvement and high-risk, high-volume or problem-prone areas.

4) The governing body failed to ensure there was Quality Assurance Plan implemented

This had the potential to negatively affect all patients served by this facility.

Findings include:

Refer to A 273, A 283, A 297 and A 308 for findings.

Based on review of facility policy and procedure, observations and interviews with the staff it was determined the facility failed to ensure:

1) Pharmacy services prepared and dispensed medications in an appropriate manner.

2) Safe dispensing and distribution of all medications.

3) Proper labeling of all medications.

4) Proper mixing of intravenous admixtures using a hood.

This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to A 491, A 492, A 500 and A 501

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations

Based on review of medical records (MR) and interviews with the staff it was determined the facility failed to initiate and up date a plan of care for each patient who receives services provided by the facility and to include the patient or patient representative in the care planning process. This had the potential to negatively affect all patients served by the facility.

Finding include:

Review of 10 MR's which included 6 closed records and 4 current patient records revealed no documentation of a care plan developed or updated on any of the 10 MR's reviewed.

Review of the MR's revealed no documentation the patient or the patient representative were included in the development of the plan of care nor was there documentation the plan of care was discussed with the patient or patient representative.

On 8/1/18 at 11:10 AM the surveyor went to Employee Identifier (EI) # 2, Director of Nursing, and inquired about careplans being competed on each patient admitted to the facility. EI # 2 stated "we do no do careplans on the patients." The surveyor then asked EI # 2 how care is provided to each patient during their stay. EI # 2 replied by stating " we go according to the doctors orders.

An interview was conducted on 8/1/18 at 11:45 AM with EI # 2 who confirmed the above mentioned findings.

Based on review of facility policy and procedures, observations and interviews with the staff it was determined the facility failed to provide as safe environment for repackaging, dispensing and medication administration to each patient.

This had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Filling Orders
Date Revised: 11/13

Policy:

All medications dispensed in Georgiana Medical Center must meet specific standards and be dispensed under the direct supervision of a Pharmacist.

Procedure:

4. All medications dispensed must be appropriately labeled with medications name, strength and expiration date...

Policy: Intravenous Admixture - Laminar Flow Hood
Policy Date: September 2009

Policy:

"It is the policy of Georgiana Hospital to utilize the laminar flow hood for intravenous admixtures. Any mixtures/medications that are to be added to fluids or medications that are to be diluted, drawn out of a vial/ampule and added to fluids must be prepared in a contamination free environment."

A tour of the facility was conducted on 7/31/18 at 9:30 AM by the surveyors. A tour of an empty patient room on the facilities back hall revealed an intravenous hood from pharmacy which was full of dust and dirt and not in working condition.

Observations of the medication room revealed in the controlled medication area were medication boxes made of a hard plastic and each box contained individual dividers within the box creating multiple individual compartments. On the outside of the plastic box was the name of the medication and strength written with a pen and no other information was present. EI # 2, Director on Nursing, opened one of the boxes and in each individual compartment was one loose pill.

When the surveyor asked Employee Identifier (EI) # 2 why the pills were loose in the box. EI # 2 stated "that's how it has always been." The surveyor asked where the expiration date and the lot number was. EI # 2 stated "the expiration date and lot number have never been put on the box by the pharmacist." EI # 2 stated "the pharmacist removes the pills from the individual dose pack, puts them in an envelope then brings them to the nursing medication room and places each pill in the box and puts the lid on."

On 8/1/18 at 9:05 AM the surveyor asked EI # 2 to escort the surveyor to the pharmacy to view how medications are shipped to the pharmacy. The surveyor and EI # 2 entered the pharmacy and observed the medication bins within the pharmacy. The surveyor observed dose packages of multiple medications and larger bottles of other medications. The surveyor asked EI # 2 if the medications come in a dose package why the pharmacist removes them when taken to the medication room at the nurses station or to the patients drawers in the medication cart. EI # 2 stated he/she did not know.

The surveyor asked EI # 2 if the pharmacist had empty dose packs that could be filled and labeled for the medications that come in a large quantity bottle. EI # 2 stated "the pharmacist before this one did and he/she made labels and placed the labels on the dose pack. EI # 2 stated the label had the medication name, strength, lot number and expiration date." EI # 2 stated she does not know why the current pharmacist does not do it that way.

The surveyor asked EI # 2 how medications are dispensed to the patients. EI # 2 stated "the pharmacist takes them out of the bottle and puts the pill in a small envelope with the name of the medication and strength or he/she takes the pill out of the dose pack and places it in an envelope and put the name of the medication and strength on the envelope." EI # 2 stated he/she was unsure of why the pharmacist removes them from the dose pack the medicine comes in.

Further observation of the pharmacy revealed no area within the pharmacy for an intravenous flow hood for mixture of medications in a contamination free environment.

An interview was conducted on 8/1/18 at 11:40 AM with EI # 6, Director of Pharmacy.

EI # 6 was asked why he/she does not mix the IV admixtures in pharmacy and the nurses are completing this in the nursing medication room. EI # 6 replied by saying "what's the difference all you do is pull the medicine out of one bottle and put it in a bag." The surveyor explained the surveyor was knowledgeable in the procedure but why was he/she not completing the task and labeling it and delivering it to the nursing medication room. EI # 6 replied by saying "Well I guess I can."

An interview was conducted on 8/1/18 at 9:30 AM with EI # 2 who confirmed the above mentioned findings.

Based on review of the Quality Improvement documentation and interviews, it was determined the facility failed to implement a Quality Improvement Plan to include quality indicators and collection of data. This had the potential to negatively affect all patients served by this facility.

Findings include:

Review of the documentation within the Quality Assurance Performance Improvement (QAPI) binder revealed no documentation of the findings to include measuring and assessing the performance of hospital services through the collection and analysis of data and the conducting of quality improvement initiatives and taking action where indicated, including the design of new services, and or improvement of existing services.

The surveyor asked EI # 1 what areas for improvement were identified and what actions were taken for improvement and were these areas tracked and trended. EI # 1 responded by saying there was no documentation of areas identified nor was there any tracking or trending data.

An interview was conducted on 8/2/18 at 2:30 PM with EI # 1 who confirmed the above mentioned findings.

Based on review of the Quality Assurance Performance Improvement (QAPI) documentation and interviews with the staff it was determined the facility failed to ensure:

1. Data was collected from each department within the hospital.

2. Areas for improvement were identified.

3. High-risk, high-volume or problem-prone areas were identified.

4. Actions were taken for improvement, those actions were measured and tracked to determine if improvements were achieved.

This had the potential to negatively affect all patients served by the facility.

Findings include:

Review of the QAPI binder presented to the surveyor on 8/2/18 at 9:45 AM revealed no documentation by each department within the hospital for the QAPI program and the results obtained from the indicators performed by each department.

An interview was conducted on 8/2/18 at 12:30 PM with Employee Identifier (EI) # 1, Administrator, who stated there were no actual PIP's (Performance Improvement Projects) initiated and there was no documentation as to improvement of each department within the hospital. When asked if the governing body determines the number of improvement projects to be conducted annually EI # 1 stated "no." The surveyor then asked EI # 1 who and how is the QAPI program evaluated EI # 1 states "it is not evaluated by anyone."

The surveyor asked EI # 1 what areas for improvement were identified and what actions were taken for improvement and were these areas tracked and trended. EI # 1 responded by saying there was no documentation of areas identified nor was there any tracking or trending data.

An interview was conducted on 8/2/18 at 2:30 PM with EI # 1 who confirmed the above mentioned findings.

Based on review of the Quality Assurance Performance Improvement (QAPI) documentation and interviews with the staff it was determined the facility failed to ensure Performance Improvement Projects (PIP) were developed by each area of the hospital, measurable progress was achieved and incorporated into the hospital-wide QAPI program.

This had the potential to negatively affect all patients served by the facility.

Findings include:

An interview was conducted on 8/2/18 at 12:30 PM with Employee Identifier (EI) # 1, Administrator, who stated there were no actual PIP's initiated and there was no documentation as to improvement of each department within the hospital. When asked if the governing body determines the number of improvement projects to be conducted annually EI # 1 stated "no."

An interview was conducted on 8/2/18 at 2:30 PM with EI # 1 who confirmed the above mentioned findings.

Based on the review of the Quality Assurance documentation and interviews, it was determined the governing body of the facility failed to ensure there was a Quality Assurance Plan implemented. This had the potential to negatively affect all patients served by this facility.

Findings include:

An interview was conducted on 8/2/18 at 12:30 PM with Employee Identifier (EI) # 1, Administrator. When asked if the governing body determines the number of improvement projects to be conducted annually EI # 1 stated "no." The surveyor then asked EI # 1 who and how is the QAPI (Quality Assurance Performance Improvement) program evaluated EI # 1 states "it is not evaluated by anyone."

An interview was conducted on 8/2/18 at 2:30 PM with EI # 1 who confirmed the above mentioned findings.

Based on review of medical records (MR) and interviews, it was determined the nursing staff failed to:

1. Follow physician order related to obtaining daily weights.

2. Perform wound assessments and document wound care.

This affected 3 of 17 MR's reviewed and did affect Patient Identifier (PI) # 3, PI # 7, PI # 10,and had the potential to negatively affect all patients served by the facility.

Findings include:

A request was made by the surveyor for a copy of the Wound Assessment policy. The surveyor was provided a page entitled "Wound Care Chart Review, Date Written: July 2012," with the following statement:

"The purpose of the Wound Care Chart Review is to ensure that quality care is provided to the patient as per physician orders. Monitoring will be done on all wound care records..."

The page contained no instructions for wound assessment, or what was being monitored.

1. PI # 3 was admitted to the hospital on 7/27/18 with an admitting diagnosis of Weakness.

Review of the Physician orders dated 7/27/18 revealed an order for "Daily weights".

Review of the Patient Progress Notes revealed no documentation of a weight on 7/29/18, 7/30/18, 7/31/18 and 8/1/18.

Further review of the Patient Progress Notes revealed documentation on 7/30/18 "attempted to weigh patient, patient too unstable" and on 7/31/18 "weight omitted, patient too weak to stand".

An interviewed was conducted on 7/31/18 at 12:40 PM with Employee Identifier (EI) # 2 , Registered Nurse, Director of Nursing, who confirmed the above findings and stated daily weights for PI # 3 were to be taken with the bed scale and not on standing scale.



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2. PI # 7 was admitted to the hospital on 7/16/18 at 2:20 PM with diagnoses including Head Injury and Brain Mass.

Review of the MR revealed the first wound assessment by the nurse was on 7/17/18 at 10:16 AM. There was no depth of the wound documented. The nurse documented "dressing changed per orders." The surveyor was unable to determine what wound care was performed. There was no documentation of the head laceration.

On 7/18/18 at 8:55 AM the nurse documents dressing changed per orders. The surveyor was unable to determine what wound care was performed.

During an interview on 8/2/18 at 1:47 PM with EI # 2, the above findings were confirmed.

3. PI # 10 was admitted to the hospital on 7/9/18 with diagnoses including Cellulitis of Right Toe (Primary), Diabetes Mellitus, Type I.

Review of the MR revealed orders dated 7/9/18 for wound care as follows: "Dry dressing change BID (Twice a Day), soak foot in betadine and saline prior to dressing."

Review of the Nurses' Initial Physical Assessment dated 7/9/18 at 12:10 PM, revealed "...an ulceration noted to the bottom of the right great toe..." There was no measurement documented.

The nurse documented on 7/10/18 at 7:13 PM, "Dry dressing performed as ordered." The surveyor was unable to determine what wound care was performed.

There was no wound care documented on 7/12/18.

On 7/13/18 at 10:31 AM the nursed documented the following, "...pt (patient) in room performing toe soak/ cleaning and dressing change by self per pt request..." There is no documentation the patient was educated on wound care.

Further of the MR revealed new wound care orders dated 7/13/18: Dressing change daily with Bactroban and covered with Xeroform gauze.

Review of the nursing note dated 7/13/18 at 8:15 PM revealed the following documentation, "...Dressing to R (right) great toe dry/ secure/ intact (Patient does own dressing change)..." The surveyor was unable to determine size of wound, or wound care performed.

An interview was conducted on 8/2/18 at 10:45 AM with EI # 2, who confirmed the above findings.

Based on review of medical records (MR) and interviews with the staff it was determined the facility failed to develop nursing careplans for each patient admitted to the facility.

Findings include:

Review of 10 MR's which includes 6 closed records and 4 current patients revealed no documentation of a care plan developed or updated on any of the 10 MR's reviewed.

The surveyor on 8/1/18 at 11:10 AM went to Employee Identifier (EI) # 2, Director of Nursing, office and inquired about care plans being completed on each patient admitted to the facility. EI # 2 stated "we do no do care plans on the patients." The surveyor then asked EI # 2 how care is provided to each patient during their stay. EI # 2 replied by stating " we go according to the doctors orders."

An interview was conducted on 8/1/18 at 1:20 PM with EI # 1, Administrator, who confirmed the above mentioned finding.

Based on review of facility policies and procedures, observations, job descriptions and interviews with the staff it was determined the facility failed to ensure:

1. Proper labeling of all medications

2. Proper mixing of intravenous (IV) admixtures

3. Proper dispensing of medications

4. Keys to the narcotic box were held by the charge nurse.

5. Procedures were followed for daily narcotic checks.

6. No out of date drugs were in stock.

This had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Filling Orders
Date Revised: 11/13

Policy:

All medications dispensed in Georgiana Medical Center must meet specific standards and be dispensed under the direct supervision of a Pharmacist.

Procedure:

4. All medications dispensed must be appropriately labeled with medications name, strength and expiration date...

Policy: Intravenous Admixture - Laminar Flow Hood
Policy Date: September 2009

Policy:

"It is the policy of Georgiana Hospital to utilize the laminar flow hood for intravenous (IV)admixtures. Any mixtures/medications that are to be added to fluids or medications that are to be diluted, drawn out of a vial/ampule and added to fluids must be prepared in a contamination free environment."

Policy: Controlled Substances
Date Revised: 11/13

"Policy:

Strict control will be maintained on all controlled substances. This requires compliance with the following procedures in a joint effort by the nursing staff and the pharmacist.

Procedure:

...3. All narcotics are to be under double locks with the charge nurse being responsible for the keys. Keys are to be kept on person, not loose...

4. Controlled drugs are to be accounted for at each shift change, by nurse going off and nurse coming on duty. The daily narcotic check sheet is used for this purpose."

Policy: Out of Date Drugs
Date Revised: 11/13

"Policy:

The pharmacy will have no out of date drugs in stock. The pharmacist is responsible for pulling all out of date drugs..."

Review of the Director of Nursing Job Description and the Registered Nurse Job Description revealed no documentation throughout the job descriptions for mixing IV admixtures in the nursing medication room.

1. A tour of the facility was conducted on 7/31/18 at 9:30 AM by the surveyors. A tour of an empty patient room on the facilities back hall revealed an intravenous hood from pharmacy which was full of dust and dirt and not in working condition

Observations of the medication room revealed in the controlled medication area were medication boxes made of a hard plastic and in each box contained individual dividers creating multiple individual compartments with in the box. On the outside of the plastic box was the name of the medication and strength written with a pen and no other information was present. EI # 2, Director on Nursing, opened one of the boxes and in each individual compartment was one loose pill.

The surveyor asked Employee Identifier (EI) # 2, Director of Nursing, why the pills are loose in the box. EI # 2 stated "that's how it has always been." The surveyor asked where the expiration date and the lot number was. EI # 2 stated "the expiration date and lot number have never been put on the box by the pharmacist." EI # 2 stated "the pharmacist removes the pills from the individual dose pack, puts them in an envelope then brings them to the nursing medication room and places each pill in the box and puts the lid on."

On 8/1/18 at 9:05 AM a tour of the pharmacy was conducted.

The surveyor observed no hood or an area to prepare IV admixtures to prevent contamination within the pharmacy. EI # 2 was asked about mixing medications and if there was a hood in the pharmacy area, she replied "there is a hood but not in pharmacy. It is in a room and being stored. We no longer use the hood. The RN (Registered Nurse) mixes the medications on the floor if its needed."

The surveyor and EI # 2 entered into the medication area of the pharmacy and observed the medication bins within the pharmacy. The surveyor observed dose packages of multiple medications and larger bottles of other medications. The surveyor asked EI # 2 if the medications come in a dose package why the pharmacist removes them when taken to the medication room at the nurses station or to the patients drawers in the medication cart. EI # 2 stated he/she did not know.

The surveyor asked EI # 2 if the pharmacist had empty dose packs that could be filled and labeled for the medications that come in a large quantity bottle. EI # 2 stated "the pharmacist before this one did and he/she made labels and placed the labels on the dose pack. EI # 2 stated the label had the medication name, dose, lot number and expiration date." EI # 2 stated she does not know why the current pharmacist does not do it that way.

The surveyor asked EI # 2 how medications are dispensed to the patients. EI # 2 stated "the pharmacist takes them out of the bottle and puts the pill in a small envelope with the name of the the medication and strength or he/she takes the pill out of the dose pack and places it in an envelope and put the name of the medication and the strength on the envelope."

On 8/2/18 at 11:00 AM EI # 2 was observed mixing IV medication without utilizing Laminar flow hood or in a contamination free environment according to the hospital policy.

Review of the Director of Nursing Job Description and the Registered Nurse Job Description revealed no documentation throughout the job descriptions for mixing IV admixtures in the nursing medication room.

An interview was conducted on 8/2/18 at 11:30 AM with EI # 2 who confirmed the above mentioned findings.




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2. A tour of the medication room located beside the nurses station was conducted on 7/31/18 at 12:35 PM. EI # 2 was also present on the tour.

Review of the End of Shift Narcotic Count Sheet located in a notebook in the medication room revealed the following shifts did not contain the On Coming and Off Going nurses' signatures:

No On Coming 7P (PM) signature: 7/20/18, 7/27/18.

No Off Going 7A (AM) signature: 6/18/18, 6/29/18, 7/25/18, 7/26/18.

EI # 2 stated, "...the form should always be signed, but sometimes they forget."

The surveyor asked EI # 2 to demonstrate how narcotics are secured. EI # 2 opened a drawer in the medication room and picked up a set of keys, and unlocked the cabinet door, and then unlocked the box containing the narcotics.

The surveyor asked if that is where the keys are usually kept and EI # 2 stated, "Yes," then further explained the charge nurse on the floor should keep them in her/his pocket.

Review of the narcotic box revealed the following:
1- Morphine Sulfate 100 mg (milligrams)/ 5 ml (milliliters) multidose bottle, opened and unlabeled.
4- Demerol 25 mg/ 0.5 ml ampule's, expired 1 Jun (June) 2018.
Multiple narcotics in the pill trays had no expiration dates.

Review of the remaining medications in the medicine cabinets revealed the following:
Bottom shelf refrigerator:
1- 10 ml multidose vial Humulin 70/ 30 insulin, opened and unlabeled.
1- 10 ml multidose vial Humulin R (Regular) 100 u (units)/ ml, opened and unlabeled.
1- Tuberculin PPD (Purified Protein Derivative) 5 u/ 0.1 ml, labeled opened on 5/22/18.
1- 10 ml multidose vial Lantus insulin 100 u/ ml, opened and unlabeled.
2- 10 ml multidose vials Levemir insulin 100 u/ ml, opened and unlabeled.
1- unopened 5 ml multidose vial Flu Vac (Vaccine), expired 6/30/18.

Lower shelf:
3- Racepinephrine Inhalation Solution 2.25 %, 2 expired 11/17, 1 expired 11/15.
1- 60 ml vial Clindamycin, labeled opened 5/16/18.
3- Ampicillin 1 Gram for injection, expired 4/18.
1- 1 ml vial Nalbuphine, expired 2/2018 (Not in locked box).
1- multidose bottle Ranitidine 15 mg/ ml, opened and unlabeled.
1- Jevity 8 ounce, expired 4/1/18.
1- secondary IV (Intravenous) set, expired 9/17.

An interview was conducted on 7/31/18 at 2:00 PM with EI # 2, who was present on the tour, confirmed the above findings.

Based on review of facility policies and procedures, observations and interviews with the staff it was determined the agency failed to ensure pharmacy services prepared and dispensed medications in a safe and appropriate manner.

This had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Filling Orders
Date revised: 11/13

"Policy:

All medications dispensed in Georgiana Medical Center must meet specific standards and be dispensed under the direct supervision of a Pharmacist.

Procedure:

1. The Pharmacist will fill the medication carts as needed.

4. All medication dispensed must be appropriately labeled with medications name, strength, and expiration date...

5. If the Pharmacist or Pharmacy Technician is unavailable, the Charge Nurse may fill the patients medication order from the pharmacy..."

Policy: Medication Carts
Date Revised: 11/13

Policy:

Georgiana Medical Center Pharmacy uses the unit dose form of medications when possible. The patients' medications are stored in medication carts between dispensing and administration.

Policy: Intravenous Admixture - Laminar Flow Hood
Policy Date: September 2009

Policy:

"It is the policy of Georgiana Hospital to utilize the laminar flow hood for intravenous admixtures. Any mixtures/medications that are to be added to fluids or medications that are to be diluted, drawn out of a vial/ampule and added to fluids must be prepared in a contamination free environment."

1. A tour of the facility was conducted on 7/31/18 at 9:30 AM by the surveyors.

During the tour an empty patient room on the facilities back hall revealed an intravenous hood from pharmacy which was full of dust and dirt and not in working condition

During the tour the medication storage room across from the nurses station was observed.

During the observation of the medication room the surveyors observed in the controlled medication box were plastic boxes with dividers inside creating multiple individual compartments each with one loose pill. On the out side of the plastic box was the name of the medication and dose written with a pen.

When the surveyor asked Employee Identifier (EI) # 2, Director of Nursing, why the pills are loose in the box, EI # 2 stated "that's how it has always been." The surveyor asked where the expiration date and the lot number was located. EI # 2 stated "the expiration date and lot number have never been put on the box by the pharmacist." EI # 2 stated "the pharmacist removes the pills from the individual dose pack, puts them in an envelope then brings them to the nursing medication room and places each pill in the box and puts the lid on."

On 8/1/18 at 9:05 AM the surveyor asked EI # 2 to escort the surveyor to the pharmacy to view how medications are shipped to the pharmacy. The surveyor and EI # 2 entered the pharmacy and observed the medication bins within the pharmacy. The surveyor observed dose packages of multiple medications and larger bottles of other medications. The surveyor asked EI # 2 if the medications come in a dose package why the pharmacist removes them when taken to the medication room at the nurses station or to the medication cart. EI # 2 stated he/she did not know.

The surveyor asked EI # 2 if the pharmacist had empty dose packs that could be filled and labeled for the medications that come in a large quantity bottle. EI # 2 stated "the pharmacist before this one did and he/she made labels and placed the labels on the dose pack. EI # 2 stated the label had the medication name, dose, lot number and expiration date." EI # 2 stated she does not know why the current pharmacist does not do it that way.

The surveyor asked EI # 2 how medications are dispensed to the patients. EI # 2 stated "the pharmacist takes them out of the bottle and puts the pill in a small envelope with the name of the medication and strength or he/she takes the pill out of the dose pack and places it in an envelope and put the name of the medication on the envelope." EI # 2 stated he/she was unsure of why the pharmacist removes them from the dose pack.

An interview was conducted on 8/1/18 at 9:30 AM with EI # 2 who confirmed the above mentioned findings.

Based on review of the Director of Pharmacy job description, policy and procedure, observations and interviews with the staff it was determined the facility failed to ensure proper supervision by the pharmacist.

This had the potential to negatively affect all patients served by the facility.

Findings include:

Review of the Director of Pharmacy job description revealed the following:

Essential Functions:

1. Oversees and assists with unit-dose preparation

4. Coordinates the pharmacy function with the nursing service and the medical staff.

6. Inspects and re-stocks the crash carts on the unit and in the emergency department.

Policy: Medications: Monthly Pharmacy Inspections
Date revised 11/13

Policy:

To maintain a supply of medications which are in date and safe for use by patients, periodic inspections of the hospital drug supply by pharmacy personnel is needed.

Procedure:

1. Each month the pharmacist shall see that all different drug stocks around the hospital are in keeping with hospital standards ( i.e., in date, correct inventory, etc.)

2. Each check will be documented at the site of inspection. That is on each emergency cart, kit, etc. The pharmacy employee will sign his/her name along with the date checked and lock number of the replacing plastic lock.

1. A tour of the facility was conducted on 7/31/18 at 9:30 AM by the surveyors. During the tour the medication storage room across from the nurses station was observed.

The surveyor asked Employee Identifier (EI) # 2, Director of Nursing, why the pills are loose in the box and where the expiration date and the lot number was. EI # 2 stated " the expiration date and lot number have never been put on the box by the pharmacist." EI # 2 stated "the pharmacist removes the pills from the individual dose pack, puts them in an envelope then brings them to the nursing medication room and places each pill in the box and puts the lid on."

On 7/31/18 during the tour the crash cart in the nursing unit was opened and medications and supplies were observed for expiration dates. During the inspection of the crash cart the following medications were found to be expired:

Nitroglycerine Paste in single dose packets all packets expired 8/1/18
3 - Heparin lock prefilled syringes expired May 2018
1 - 0.9 % Normal Saline bottle 250 milliters (ml) expired May 2018

The surveyor informed EI # 2 of the expired medications with in the crash cart on 7/31/18 at 2:30 PM.

On 8/1/18 at 9:05 AM the pharmacy area was observed to view how medications are shipped to the pharmacy. The surveyor and EI # 2 entered the pharmacy and observed dose packages of multiple medications and large bottles of medications. The surveyor asked EI # 2 if the medications come in a dose package why the pharmacist removes them when taken to the medication room at the nurses station or to the medication cart. EI # 2 stated he/she did not know.

The surveyor asked EI # 2 how medications are dispensed to the patients. EI # 2 stated "the pharmacist takes them out of the bottle and puts the pill in a small envelope with the name of the medication and strength or he/she takes the pill out of the dose pack and places it in an envelope and puts the name of the medication on the envelope." EI # 2 stated he/she was unsure of why the pharmacist removes the pills from the dose pack the medicine comes in.

An interview was conducted on 8/1/18 at 11:40 AM with EI # 6, Director of Pharmacy.

The surveyor asked EI # 6 why he/she does not mix the IV (Intravenous) medications in the pharmacy and the nurses are completing it in the medication room. EI # 6 responded by saying "what's the difference you pull the medicine out of the bottle and put it in a bag."

The surveyor asked EI # 6 if he/she completes any type of supervisor form to ensure RN's (Registered Nurses) are performing the correct procedures for adding medications to the IV bags and his/her response was "no I don't."

An interview was conducted on 8/2/18 at 11:30 AM with EI # 2 who confirmed the above mentioned findings.

Based on review of facility policies and procedures, observations and interviews with the staff it was determined the facility failed to ensure safe dispensing and distribution of all medications for each patient admitted to the facility.

Findings include:

Policy: Filling Orders
Date revised: 11/13

"Policy:

All medications dispensed in Georgiana Medical Center must meet specific standards and be dispensed under the direct supervision of a Pharmacist.

Procedure:

1. The Pharmacist will fill the medication carts as needed.

4. All medication dispensed must be appropriately labeled with medications name, strength, and expiration date...

5. If the Pharmacist or Pharmacy Technician is unavailable, the Charge Nurse may fill the patients medication order from the pharmacy..."

Policy: Medication Carts
Date Revised: 11/13

Policy:

Georgiana Medical Center Pharmacy uses the unit dose form of medications when possible. The patients' medications are stored in medication carts between dispensing and administration.

1. A tour of the facility was conducted on 7/31/18 at 9:30 AM by the surveyors. During the tour the medication storage room across from the nurses station was observed.

During the observation of the medication room, the medications were observed without proper medication labels according to hospital policy. The surveyor asked where the expiration date and the lot number was. EI # 2 stated "the expiration date and lot number have never been put on the box by the pharmacist." EI # 2 stated "the pharmacist removes the pills from the individual dose pack, puts them in an envelope then brings them to the nursing medication room and places each pill in the box and puts the lid on."

On 8/1/18 at 9:05 AM the surveyor entered the pharmacy area to view how medications are shipped to the pharmacy. The surveyor observed dose packages of multiple medications and large bottles of medications. The surveyor asked EI # 2 if the medications come in a dose package why the pharmacist removes them when taken to the medication room at the nurses station or to the medication cart. EI # 2 stated he/she did not know.

An interview was conducted on 8/1/18 at 9:30 AM with EI # 2 who confirmed the above mentioned findings.

Based on a tour of the Dietary Department, interviews, and review of policies and procedures, it was determined the Dietary Department failed to ensure:

1. Opened foods were labeled appropriately.
2. Expired food was discarded.
3. Menus approved by the Registered Dietitian were being followed.
4. Gloves were worn during food preparation.
5. Employees knew how to extinguish a grease fire in the kitchen.

This had the potential to affect all people served by the Dietary Department.

Findings include:

Policy: Food Service Manager's Responsibilities
Date Reviewed: 2010

"Policy:

A well-trained food service manager assures that instructions for the food service department are properly carried out, and that all local, state and federal food, food safety and sanitation regulatory requirements are met.

Procedure:

...2. The food service manager is familiar with all local, state and federal regulatory requirements related to food, food safety and sanitation; and assures that all requirements are met.

3. Workers are trained, assisted....

6. ...Staff follows proper sanitation and food handling practices. Food is served as soon as possible after it has been prepared, and at the proper safe temperature.

10. ...Equipment is properly used, cleaned and sanitized, and kept in good repair.

11. There is variety in the menus and in the appearance of the foods.

Policy: Food Storage
Date Reviewed: 2010

"Policy:

Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing...

Procedure:

8. All stock must be rotated with each new order received...
a. Old stock is always used first.
b. Supervise the person designated to put stock away to make sure it is rotated properly.
c. Food should be dated as it is placed on shelves.
d. Date marking to indicate the date or day by which a ready-to-eat, potentially hazardous food should be consumed, sold, or discarded...

13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded.

14. Refrigerated Food Storage:
f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable) or discarded...

15. Frozen Foods:
d. All foods should be covered, labeled and dated..."

Policy: Fire Plan for Food Service Department
Date Reviewed: 2010

"Policy:

All food service employees follow the fire plan for the department. Staff will be well trained on fire safety.

Procedure:

2. Staff will be trained on procedures to follow in the event of a fire...

3. Procedures to follow for different types of fires:
a. Never put water on a grease fire.
c. If a fire is large and uncontrolled and exists in range area or hoods, use overhead fire extinguishers."

Policy: Fire Safety Rules
Date Reviewed: 2010

"Policy:

All employees should be aware of rules to follow in a fire emergency.

Procedure:

2. If the fire is small and confined to a burner or a pan skillet fire, smother by covering with a pan lid or using baking soda.

3. DO NOT use water as a means of extinguishing any fire that involves grease.

5. In the event that the fire is large, pull the nearest fire alarm box..."

1. A tour of the Dietary Department was conducted on 7/31/18 at 2:50 PM. The following items were observed:

Dry Storage area:
4- 2 oz (ounce) bottles of Tabasco, expiration date 3/14.
1- jar of white, flaky substance, unlabeled for content and date.
2- 2 lb (pound) packages of spaghetti noodles, opened, unsealed, and unlabeled with date.

Walk in Cooler:
1- 2 lb bag self rising flour, opened and unlabeled with date.
1- plastic container of red liquid, unlabeled for content, dated 7/19/18.
1- gallon container of pickle relish, opened and unlabeled.
1- box of cranberry sauce packets (1/2 oz each), expired 11/10/16.
1- box of cocktail sauce packets (3/4 oz each), expired 8/24/15.
50- 1000 Island dressing packs (1.5 oz each), expired 5/18/18.

Double Refrigerator in kitchen:
2- opened bottles of Powerade (belonged to employees).
1- 5 lb bag shredded cheese, opened and unlabeled.
1- plastic bag of crackers, unlabeled for content and date.
1- pack of sliced turkey breast, expired 4/29/18.
1- container of jelled substance, unlabeled for content and date.

Box Freezer in kitchen:
1- large bag of fries, opened and unlabeled.
1- large bag okra, opened and unlabeled.
2- large bundles of hot dogs, out of original packing, wrapped in foil, unlabeled for content and date.
1- large bag of steak nuggets, opened and unlabeled.
1- large bag of chicken breasts, opened and unlabeled, expired 4/19/18.
1- bag of vegetables, opened and unlabeled.
1- bag of sausage, opened and unlabeled.
1- bag of cubed steak, opened and unlabeled.
1- bag of chicken fingers, opened and unlabeled.

An interview was conducted on 7/31/18 at 4:00 PM with Employee Identifier (EI) # 8, Dietary Aide, who was also present on the tour and confirmed the above findings.

2. During observation of food preparation and plating of food for patients on 8/1/18 at 11:45 AM, the surveyor observed EI # 9, Dietary Director, preparing chicken breasts for the patients lunches. Review of the Week 5 meal rotation menu, which EI # 9 stated they were following, revealed the following menu for Wednesday lunch:

"Chicken and Rice Casserole
Green Beans
Cheddar Biscuit
Cookies"

The surveyor asked EI # 9 was she/he preparing any of the food on this list. EI # 9 responded, "No, sometimes we have to go with what we are cooking for employees, we are short handed."

Posted on the wall outside the kitchen was the Employee Meal dated 8/1/18 with the following items listed:

"Chicken Patty Sandwich
French Fries
Fruit Cocktails"

On 8/2/18 at 11:00 AM, the surveyor returned to the Dietary Department to observe what food items were being prepared for patient lunches. According to the Week 5 schedule, Thursday's lunch should include:

"Taco Salad
Lettuce
Tomato
Cheese
Ice Cream"

The surveyor asked EI # 9 if the above items were being served to patients. She responded "No, the menu for today is hamburger steak and spinach."

An interview was conducted by phone on 8/2/18 at 2:20 PM with EI # 10, Registered Dietitian, who confirmed the Dietary Director should not be making substitutions to the approved menus. EI # 10 stated she/he thought the kitchen was now on a 2 week menu rotation.

3. During the plating of patient lunches on 8/1/18 at 12:00 PM, the surveyor observed EI # 9 slicing bread with gloved hands. EI # 9 dropped a white bag used to hold the sliced bread, on the floor. After picking up the bag off of the floor, EI # 9 removed gloves, failed to wash hands, and continued slicing bread with ungloved hands, placed the bread in white bags, and placed the bags on the patient trays.

During the temperature monitoring of the patients' food, EI # 9 handled fries and the thermometer with ungloved hands.

The surveyor observed EI # 9 use the counter mounted can opener. The opener appeared to have a black greasy substance on the opener that pierces the can.

An interview was conducted by phone on 8/2/18 at 2:20 PM with EI # 10, who confirmed staff should wear gloves when handling food.

4. An interview was conducted on 8/1/18 at 1:30 PM with EI # 8, Dietary Aide. The surveyor asked what she/he would do if a grease fire occurred on the stove. EI # 8 stated she would call 911. When the surveyor asked what would he/she do with the fire, she/he stated, "Would I through water on it?" EI # 8 was also unaware of the overhead extinguisher above the stove.

During an interview conducted on 8/1/18 at 1:45 PM with EI # 10, it was confirmed EI # 8 had not been trained on fire safety.

Based on review of personnel files, the facility failed to document orientation of newly hired dietary personnel. This deficient practice had the potential to negatively affect all patients receiving meals from the hospital dietary department.

Findings include:

1. Employee Identifier (EI) # 8, Dietary aide, was hired at the hospital on 7/18/18.

Review of the personnel file for EI # 8 was conducted on 8/2/18 at 11:48 AM which revealed no documentation of general or dietary orientation for EI # 8.

An interview was conducted on 7/31/18 at 12:40 PM with EI # 2, Director of Nursing, who confirmed the above mentioned findings.

Based on observations, facility policy and procedure and interviews with the staff it was determined the facility failed to ensure all equipment was tested for performance and safety on an annual basis and all medical supplies and medications were not expired and in use for patient care.

This had the potential to negatively affect all patient served by the facility.

Findings include:

Georgiana Medical Center
Safety Manual

"Equipment Calibration and Preventive Maintenance

Georgiana Medical Center has (persons Name) who is certified and responsible for the calibration of new equipment and preventive maintenance of patient service equipment and repairs as needed.

(Persons Name) maintains the records of maintenance of equipment used for patient care. These services are performed on an annual basis or as needed for repairs, recalibration's or emergency needs."

Policy: Medications: Monthly Pharmacy Inspections
Date revised 11/13

"Policy:

To maintain a supply of medications which are in date and safe for use by patients, periodic inspections of the hospital drug supply by pharmacy personnel is needed.

Procedure:

1. Each month the pharmacist shall see that all different drug stocks around the hospital are in keeping with hospital standards ( i.e., in date, correct inventory, etc.)

2. Each check will be documented at the site of inspection. That is on each emergency cart, kit, etc. The pharmacy employee will sign his/her name along with the date checked and lock number of the replacing plastic lock."

1. A tour of the facility was conducted on 7/31/18 at 9:00 AM. During the tour all patient rooms except the occupied room were entered and inspected. All storage rooms which contained supplies observed.

The surveyor entered room 114 which was a patient room but used as a storage room for extra equipment. In the room was a Hoyer lift which did not have a preventive maintance (PM) sticker showing the last time the Hoyer lift was inspected for safety.

The surveyor then entered the back hall storage area which contained house keeping supplies and medical supplies and clean equipment i.e., bed side commode chairs. After further observation the surveyor noticed a bucket from a bedside commode was sitting under duct work which was in the ceiling and the bucket was on the floor. Further observation of the bucket revealed a clear liquid in it and the surveyor was unsure of what the liquid was.

Observation of the old nurses station on the back hall revealed 5 boxes of 100 each 22 gage 1 inch needles which expired 2/18.

The surveyor then went to the second storage room on the back hall. The following items were found:
1 - Adview vital sign pump without a PM sticker .
1- Oxygen concentrator with out a PM sticker.

The surveyor then entered the nursing area and opened the crash cart.

The following medications and supplies were found in the crash cart and were expired:

All packets of Nitroglycerine Paste single dose use expired 8/1/18

3 - prefilled syringes of Heparin lock solution expired 5/2018

4 -Flexi Slip size 12 Fr. (French) 4.0 mm (millimeters) expired 12/17

1 - 250 ml (milliters) bottle of NS (Normal Saline) which was in the Dobutamine package expired 5/18.

The surveyor continued the tour of the hospital and behind the nursing station was a storage room. The following items were found in the storage room and were expired:
1- Siemens Multi Stix (used to measure kidney function and blood sugars) expired 6/16.

1 - 500 ml bottle 0.9% Irrigation solution opened and expired 5/18.

1 - Para Pak Ecofix ( stool examination packet) expired 1/18

1 - Para Pak C & S (culture and sensitivity) expired 6/18

1 - Para Pak Ecofix expired 12/16

The surveyor then entered room 117 which is used for overflow for Emergency Room patients.

The following supplies were found to be expired:

1 - 500 ml bottle of Sterile water opened with no open date present.

1 - 500 ml bottle of NS opened with no open date present.

1 - 8 fluid ounce bottle of Betadine open with a open date of 10/17/17 which is past the 28 day use after opening.

1 - sterile specimen cup seal broken and lid loose.

The surveyor then entered Exam room # 1 of the Emergency Department and the following medications/supplies were expired:

1 - 8 ounce bottle of Betadine had an open date of 4/18.

1 - 8 ounce bottle of Betadine had an open date of 5/1/18.

1 - 500 ml bottle of sterile water with no open date documented.

1 - 8 ounce bottle of Betadine with an open date of 1/1/17.

An interview was conducted on 7/31/18 at 1:30 PM with Employee Identifier # 2, Director of Nursing who confirmed the above mentioned findings.



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2. The surveyor, accompanied by EI # 7, Emergency Room Registered Nurse, entered Exam room # 1 of the Emergency Department on 8/4/18 at 11:20 AM. The following IV (Intravenous) fluids in a bin on the supply shelf were expired:

8 - 1000 ml bags of D5 (5 percent Dextrose) 1/4 (one forth) Normal Saline, expired 7/2018.

The surveyor then inspected the equipment in Exam room # 1. The following item was found:
1 - Adview vital sign pump with a PM sticker that expired 5/18 .

An interview was conducted on 7/31/18 at 12:40 PM with EI # 2, who confirmed the above mentioned findings.



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3. A tour of the facility was conducted on 7/31/18 at 11:15 AM. The following items were overdue for preventive maintenance (PM), or missing a PM sticker:

Room 114 used for storage:
1- Flo Lab machine, Model 2100- SX, no PM sticker.

Lab storage room:
1- Horizon Centrifuge, PM due 5/18.

Old Nurses' station:
1- Abbott Glucometer, PM due 5/18.

Hall storage closet:
1- Nebulizer, PM due 5/18.

Hall outside of patient rooms:
Oxygen Concentrator, PM due 5/18.

During observation of medication passes, the surveyor observed the nurse administer a breathing treatment to an unsampled patient. The nebulizer used for the treatment contained a PM sticker due 5/18.

Located in the same room with the medications, was the nurses' breakroom. The following was observed on the shelves:
-On the same shelf with O2 (Oxygen) cannula's was an opened personal bottle of water, and opened Coke.
-On the same shelf with water bottles for the O2, was an opened jar of dill pickles.
-Personal purses and lunch bags were sitting on O2 tubing, face masks, tracheostomy masks, and incentive Spirometry tools.
- Bag containing personal food sitting on Air Embolism Stockings.
- Paper plates laying on a stethoscope.

An interview was conducted on 7/31/18 at 2:00 PM with EI # 2, who was present on the tour, confirmed the above findings.

Based on review of the Emergency Preparedness binder and interviews with the administrator it was determined the facility failed to ensure the collaboration with state and local emergency preparedness officials' to include all documentation of the collaboration.

This had the potential to negatively affect all patients served by the facility.

Findings include:

Review of the Emergency Preparedness Program on 8/2/18 at 9:15 AM revealed the facility failed to provide documentation of the collaboration with the state and local officials.

During an interview on 8/2/18 at 2:00 PM with Employee Identifier (EI) # 1, Administrator, EI # 1 stated " We did not contact anyone from the state or local fire department or police and we do not have anything documented." EI # 1 confirmed the above mentioned findings.

Based on review of the Emergency Preparedness Program binder and interviews with the staff it was determined the facility failed to include a policy and procedure for the use of volunteers during an emergency.

This had the potential to negatively affect all patients served by the facility.

Finding include:

Review of the Emergency Preparedness Program program on 8/2/18 at 9:15 AM revealed the facility failed to provide a policy and procedure for the use of volunteers during an emergency situation. The surveyor found in the binder a letter stating the hospital does not have volunteers.

EI # 1 confirmed the above mentioned findings.

Based on review of the Emergency Preparedness Program it was determined the facility failed to provide an emergency preparedness communication plan.

This had the potential to negatively affect all patients served by the facility.

Findings include:

Review of the Emergency Preparedness Program on 8/2/18 at 9:15 AM revealed no documentation of a communication plan for the primary and any alternate means of communication with the staff or the local or state agencies during an emergency.

An interview was conducted with Employee Identifier # 1, Administrator, who confirmed the above mentioned finding.

Based on review of the Emergency Preparedness Program, review of employee files and interviews with the staff it was determined the facility failed to provide initial or annual training to the employees for emergency preparedness.

This had the potential to negatively affect all patients served by the facility.

Findings include:

Review of the Emergency Preparedness ( EP) Program and employee files on 8/2/18 at 10:00 AM reveled no documentation of the initial training or annual training for the EP Program.

An interview was conducted on 8/2/18 at 9:30 AM with Employee Identifier # 1, Administrator, who confirmed the above mentioned findings.