HospitalInspections.org

Based on MR (medical record) reviews, hospital policy and procedure, and staff interviews it was determined the facility failed to ensure nursing staff:

1. Identified patients with nutritional risks and notified the dietician to complete a nutritional assessment which affected PI (Patient Identifier) # 4, in one of one tube feeding record reviewed and PI # 8, in one of one wound record reviewed.

2. Followed the physician order and completed neuro (neurlogical) check assessments which affected one of one Dextox record reviewed and included PI # 1.

This had the potential to negatively affect all patients admitted to the hospital.

Findings include:

Hospital Policy and Procedure:
Subject: Nutritional Assessments
Reviewed: 3/11/2020

Policy:

...a. Nutritional Assessment be completed for any patient identified as having a nutritional risk with a hospital stay longer than 24 hours.

...Procedure:

1. The Case Manager (CM)...will gather screening data on all patients, within 24 hours of admission, except holidays and weekends.
2. Adults will be identified as potential risk if any of the following are noted:
a. Presence of Stage 3 or 4 decubitus
b. Patients whose diagnoses or presenting signs/symptoms indicate a compromised nutritional status...
c. Patients receiving enteral (tube feeding-TF)/parental nutrition
d. BMI (body mass index) over 40 or less than 16

3. The CM...will notify the dietician to complete nutritional assessment on patients identified as having nutritional risk factors within 24 hours of admission.

4. The consulting dietician will notify the CM...of completed assessment within 48 hours of notification...

5. CM will review recommendations made by the dietician with physician...

6. Follow-up assessments will be conducted....

7. The Nutritional Assessment will be...part of the patient's record.

1. PI # 4 was admitted to the facility on 7/21/22 (Thursday) with diagnoses including Aspiration Pneumonia and expired on 7/23/22 at 5:00 PM.

Review of physician orders dated 7/21/22 at 11:48 AM revealed Ensure 30 ml (milliliter) Q (every) 1 hour via PEG (percutaneous endoscopic gastrostomy) tube.

Review of the Nurse Initial Interview dated 7/21/22 (no time documented) revealed chief complaint was aspiration and hypoxia, the gastrointestinal medical history included the presence of a feeding tube, the last known bowel movement date was 7/21/22, all medications were administered via peg tube, and no dietary consult was necessary.

Further review of the physician entered orders dated 7/21/22 at 4:01 PM included "can try feeding pt (patient) with Glucerna po (by mouth) as tolerated, if unable to tolerate po feeding, give via peg tube".

There was no documentation nursing staff identified PI # 4's nutritional risks, which included aspiration pneumonia, and the presence of the enteral nutrition/tube feeding and requested the dietician to perform a nutritional assessment per the hospital policy and procedure.

In an interview conducted on 3/2/23 at 2:53 PM, EI (Employee Identifier) # 2, Chief Nursing Officer, confirmed nursing staff failed to identify/document PI # 4's nutritional risks and request a dietician referral for completion of nutritional assessment consult.

2. PI # 8 was admitted to the facility on 2/26/23 (Sunday) at 9:12 PM with diagnoses including Chronic Leg Wound.

Record review revealed on 2/26/23 at 3:40 PM, PI # 8's weight was 300 lb and BMI 54.87, which is greater than 40, and requires a dietary consult per hospital policy.

Review of the Nurse Initial Interview dated 2/26/23 (no time documented) revealed no known gastrointestinal medical history, the presence of wounds/ulcerations, edema and that no dietary consults was necessary.

There was no documentation nursing staff identified PI # 8's nutritional risks which included BMI greater than 40. There was no documentation the dietician was consulted to perform a nutritional assessment.

In an interview on 3/2/23 at 3:55 PM, EI # 17, Case Management/Quality Licensure Practical Nurse confirmed a dietary consult was needed due to BMI greater than 40 and no dietary consult was documented in the record.



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3. PI # 1 was admitted to the facility on 2/23/23 at 4:49 PM with a diagnosis of ETOH (Alcohol) Detox (detoxification).

Review of the MR revealed physician orders dated 2/23/23 at 5:25 PM for neuro (neurological) assessment checks every four hours for 24 hours, then every six hour for 48 hours.

Review of the Nurse Notes (NN) dated 2/23/23 at 6:24 PM and 9:30 PM revealed two neuro assessment checks were completed.The staff failed to perform neuro assessment checks every four hours as ordered.

Review of the NN dated 2/25/23 at 9:06 AM revealed one neuro assessment check was completed. The staff failed to perform neuro assessment checks every six hours as ordered.

Review of the NN dated 2/26/23 at 9:50 AM revealed one neuro check assessment was completed. The staff failed to perform neuro assessment checks every six hours as ordered.

An interview conducted on 3/2/23 at 3:27 PM with EI # 4, Director of Nursing confirmed staff failed to completed neuro assessment checks per physician's orders.

Based on Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings and Injection Medication Safety Recommendations, hospital policy and procedure, observation, and staff interview, it was determined the facility failed to ensure staff followed CDC recommendations and prepared Intravenous (IV) medication in a designated clean medication preparation area.

This affected one of one observation for IV medication preparation and administration in the ED (Emergency Department) with ED PI (Patient Identifier) # 1 and this deficient practice had the potential to negatively affect all patients served by the hospital.

Findings include:

CDC Injection Safety

Injected medicines are commonly used in healthcare settings for the prevention, diagnosis, and treatment of various illnesses. Unsafe injection practices put patients and healthcare providers at risk of infectious and non-infectious adverse events and have been associated with a wide variety of procedures and settings...

Medication Preparation Questions
FAQs regarding Safe Practices for Medical Injections

1. Where should I draw up medications?

....Medications should be drawn up in a designated clean medication preparation area...The medication preparation area should be cleaned and disinfected on a regular basis...

2. How should I draw up medications?

Parenteral medications should be accessed in an aseptic manner...

Hospital Policy and Procedure:
Reference Number 1305

Policy:

...provide personal protective equipment to all employees...to protect themselves against exposure...not limited to...gloves...

Procedure:

The appropriate personal protective equipment shall be worn when:

...Whenever there is a danger of contamination from blood, body fluids....or other potentially infectious materials...

1. Employee Identifier (EI) # 9, RN (Registered Nurse), ED, was observed on 2/28/23 at 11:10 AM at the nurse station with one 1000 ml (milliliter) bag of 0.9 % saline solution, one 100 ml bag of 0.9 % saline and one 3.375 gram vial IV Zosyn (an antibiotic) lying on the computer cart tabletop.

EI # 9 exited the nurse station with the IV Zosyn vial, and the two saline solution bags on the computer cart and entered ED two. EI # 9 reconstituted the IV Zosyn with 0.9 % saline from the 100 ml saline bag in ED two on the computer cart.

EI # 9 failed to prepare the IV Zosyn in a designated clean medication preparation area.

An interview was conducted on 3/2/23 at 3:11 PM with EI # 2, Chief Nursing Officer who confirmed medication preparation should be performed in the ED medication room, a designated clean area.

Based on review of hospital policy and procedure, observations and interview, it was determined the hospital failed to ensure food was stored in a safe and sanitary manner. This had the potential to negatively affect all patients served by the hospital.

Findings include:

Hospital Policy: Food Storage
Policy Number: 0906
Revised Date: 5/18/17

Policy:

It is the policy of Jackson Medical Center to ensure that food is stored in a safe and sanitary manner and areas be maintained in a clean, safe and sanitary manner.

Procedure:

...9. All food prepared and packaged by a food processing plant shall be clearly marked...and discarded by date indicated by processing plant.

1. During a tour of the dietary department on March 1, 2023 at 10:30 AM with the Dietary Manager, Employee Identifier (EI) # 6, the surveyor observed in the dry storage area the following items:

4 - Sysco cans of 6.38 pounds (lbs) sliced peaches with no expiration dates.
6 - Hunts 6.9 lbs of tomato sauce with no expiration dates.
2 - Sysco 6.63 lbs of whole kernel corn with no expiration dates.
2 - Sysco 6 lb 12 oz (ounce) sweet potatoes with no expiration dates.
1 - 5 lb bag of beef cubes with no expiration date.
1 - 4.34 oz Salad Supreme seasoning with use by date of 12/12/22.
6 - Sysco cans of 6.18 lbs of Spaghetti sauce with no expiration dates.
2 - Angel Mia cans of 6.5 lbs of diced tomatoes with no expiration dates.
6 - Langers bottles of 64 fluid oz. of cranberry juice with no expiration dates.

An interview was conducted on 3/1/23 at 11:00 AM with EI # 6 who confirmed the expiration dates were not listed on the cans and packages.



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Based on observations during the 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 hospital.

Findings include:

Refer to Life Safety Code violations

Based on observations, review of hospital policy and procedure, hospital crash cart log documentation and interviews, it was determined the staff failed to check, test and document the Lifepak defibrillators/crash carts were ready to use daily as directed per the hospital policy. This affected 3 of 3 defibrillators/crash carts and had the potential to negatively affect all patients receiving care at this hospital.

Findings include:

Hospital Policy: Crash Cart Checks
Policy Number: None listed
Date Issued: 06/07

Purpose:

To ensure that the crash cart equipment, drugs, and supplies are functioning, stocked appropriately, and in date.

Policy:

The charge nurse in each area of nursing service will be responsible for doing crash cart checks daily, monthly and after each use.

Procedure:

1. Ensure that all equipment on the formulary is present and functioning properly at the beginning of each shift. (Monitors, Airway equipment, etc.) ...

5. After performing all the required checks, it is the responsibility of the nurse to date, time, and initial, on the appropriate check sheet, that each crash cart was checked ...

1. During a tour of the Medical/Surgical area on 3/1/2023 at 9:00 AM, the crash cart log was reviewed. There was no documentation the cart had been checked for the following dates on the day shift (7:00 AM to 7:00 PM):
2/2/2023
2/6/2023
2/7/2023
2/14/2023
2/16/2023
2/24/2023

An interview was conducted on 3/1/2023 at 9:30 AM with Employee Identifier (EI) # 4, Director of Nursing, who confirmed there was no documentation that the defibrillator/crash cart was checked on the above dates.



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2. A tour of the ED (emergency department) was conducted on 3/1/23 from 8:15 AM until 9:15 AM with EI (Employee Identifier) # 15, Registered Nurse, ED. The ED tour included observations of two crash carts located in ED one and ED four.

There was no documentation the ED staff checked ED four emergency equipment, supplies and defibrillator monitor from on day shift on the following days:

2/6/23
2/8/23
2/16/23
2/21/23
2/28/23

There was no documentation the staff checked ED one's emergency equipment, supplies and defibrillator monitor on day shift from on the following days:

2/6/23
2/16/23

There was no documentation the staff check ED one's emergency equipment, supplies and defibrillator monitor on 2/13/23 on night shift from 7:00 PM- 7:00 AM.

During the 3/1/23 tour at 9:00 AM, an interview was conducted with EI # 15 who confirmed there was no documentation on the above dates the ED crash cart equipment, supplies including emergency drugs, were stocked appropriately, in date, and no documentation the defibrillator monitor was functional.

Based on review of hospital policies and procedures, manufactures recommendations for cleaning of the Therabands, observations and interviews with the staff it was determined the hospital failed to ensure the staff followed the hospital policy for hand hygiene, glove use and cleaning of the physical therapy Therabands. This affected ED (Emergency Department) PI (Patient Identifier) # 1, one of one patients receiving outpatient physical therapy including PI # 11, and one of one wound observations including PI # 9. This deficient practice had the potential to negatively affect all patients being served by the hospital.

Findings include:

Hospital Policy: Hand Hygiene - CDC (Centers for Disease Control) Guidelines
Reference Number: 4008

Purpose:

To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs and infections.

Policy:

Always follow Standard Precautions

Change gloves and discard after each patient contact...

Change gloves when moving from a contaminated body site to a clean body site on the same patient.

All staff shall use the hand-hygiene techniques, as set forth in the following procedure. The CDC has recommended guidelines on when to use non-antimicrobial soap and water, and antimicrobial soap and water or and alcohol-based hand rub.

When hands are soiled

Before each patient encounter

Before applying gloves...

After coming in contact with patient's intact skin...

After working on a contaminated body site and then moving to a clean body site on the same patient.

After contact with medial equipment/supplies in patent area

Always after removing gloves...

Procedure:

Using antimicrobial soap and water or non-antimicrobial soap and water:

Wet hands and apply manufacture's recommended amount of soap to hands. Lather well...

Wash hands thoroughly, using rigorous scrubbing action for at least 20-30 seconds...

Rinse hands and wrists under running water.

Dry hands with clean paper towel...

Turn off faucets with used paper towel and discard...

Hospital Policy: Medical Equipment User/Maintainer Orientation/Education
Reference Number: 1303

Policy:

Staff shall be trained to correctly use any equipment prior to use.

The employee shall be educated/trained in the following areas:

Operation of medical equipment

Disinfect...as appropriate, the medical equipment:

To include cleaning equipment surfaces...

Manufacturer Recommendations: Theraband Care and Safety

Caring for your Theraband Products:

...To clean, use mild soap and warm water, pat dry.

Store in a cool, dry place ...

1. On 3/1/23 at 9:15 AM an observation was conducted with Employee Identifier (EI) # 13, Registered Nurse (RN) - Medical Surgical area to observe a medication pass to an unsampled patient.

When entering the room EI # 13 washed hands, dried hands and turned the faucet off with his/her bare hand. EI # 13 then preceded to complete the medication pass to the patient. Prior to exiting the patient's room EI # 13 washed hands, dried hands and turned the faucet off with his/her bare hand and exited the room.

An interview was conducted on 3/2/23 at 3:45 PM with EI # 2, Chief Nursing Officer, who confirmed the nurse failed to follow the facility policy and turn the faucet off with a paper towel.



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2. EI # 9, RN, ED was observed on 2/28/23 at 11:10 AM at the ED nurse station with one 1000 ml (milliliter) bag of 0.9 % saline solution, one 100 ml bag of 0.9 % saline and one 3.375 gram vial IV (Intravenous) Zosyn (an antibiotic).

EI # 9 exited the nurse station with the IV Zosyn vial, and the two saline solution bags on the computer cart, entered ED two, reconstituted the IV Zosyn with 0.9 % saline from the 100 ml saline bag and connected the Zosyn to the existing IV site for ED PI # 1.

EI # 9 failed to perform hand hygiene before IV Zosyn preparation/administration and before contact with the patient's IV site.

An interview was conducted on 3/2/23 at 3:11 PM with EI # 2 who confirmed staff should perform hand hygiene before medication preparation/administration.

3. Observations of care on 2/28/23 at 11:14 AM in the ED included EI # 10, Phlebotomist, attempts to draw blood from ED PI # 1. After two unsuccessful venipuncture attempts, EI # 10 placed the used (dirty) tourniquet back in the red, plastic lab supply box.

EI # 10 failed to discard the single use tourniquet.

Next EI # 10 removed/discarded his/her gloves and performed hand hygiene at the sink. EI # 10 turned the faucet off with his/her hands and not paper towels.

In an interview conducted on 3/2/23 at 4:00 PM, EI # 2 confirmed staff failed to follow CDC recommendations for hand hygiene.

4. During a medication pass observation for an unsampled patient on the medical/surgical (M/S) floor on 2/28/23 at 2:00 PM, EI # 11, Licensed Practical Nurse (LPN) entered the M/S medication (med) preparation (prep) room and performed hand hygiene at the sink.

EI # 11 then exited the med prep room to the M/S hallway, retrieved the computer cart and re-entered the med prep room, computer cart in hand.

EI # 11 reviewed the unsampled patient's med orders, opened the Omnicell (an automated drug dispensing machine), retrieved a bottle of liquid Prednisone, withdrew the Prednisone from the med bottle into a syringe, then transferred the liquid Prednisone from the syringe into a med cup and exited the med prep room.

EI # 11 failed to perform hand hygiene after re-entering the med prep room and before preparing Prednisone for administration.

During an interview on 3/2/23 at 4:00 PM, EI # 2 confirmed staff are required to perform hand hygiene before medication preparation.

5. During a wound care observation for PI # 9 on 3/1/23 at 9:25 AM, EI # 12, LPN, removed and discarded the old wound dressing. EI # 14, RN, and EI # 13, RN assisted EI # 12 with care and performed hand hygiene at the sink with soap and water.

EI # 12 removed/discarded gloves and washed hands with soap and water for 9 seconds and turned off the faucet with bare hands. EI # 12 failed to wash hands thoroughly, using rigorous scrubbing action for at least 20-30 seconds and turn off the faucet with paper towels.

EI # 14 removed/discarded gloves and obtained gloves from clean glove supply without first performing hand hygiene, potentially contaminating the clean glove supply.

EI # 13 washed hands with soap and water for 5-7 seconds, then turned the faucet off with bare hands. EI # 13 failed to wash hands thoroughly, using rigorous scrubbing action for at least 20-30 seconds and turn off the faucet with paper towels.

During an interview on 3/1/23 at 9:55 AM following the wound care observation, EI # 12, EI # 14, and EI # 13 confirmed the above breaches in hand hygiene and glove use.



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6. PI # 11 was referred to the facility on 1/3/23 for Physical Therapy with diagnoses including Cervicalgia (Neck Pain) and Muscle Weakness (Generalized).

An observation was conducted on 3/1/23 at 8:15 AM in the Outpatient Rehabilitation Department.

On arrival EI # 6, License Physical Therapy Assistant (LPTA), was assisting PI # 11 with exercises using a green Theraband. The green Theraband was not cleaned per manufacturer recommendations for use or the hospital policy before returning to the clean stock supply.

An interview was conducted on 3/1/23 at 10:00 AM with EI # 6, who confirmed he/she failed to sanitize the used green Theraband prior to returning to the clean stock supply.

Based on ED (Emergency Department) policy and procedure, ED medical record (MR) review, personnel files and staff interview, it was determined the facility failed to ensure ED staff were trained and competent to prepare/administer IV (intravenous) sedation and competent to provide care in one of one ED record reviewed for a patient requiring a ventilator.

This affected ED PI (Patient Identifier) # 7 and had the potential to negatively affect all patients who receive care at the ED.

Findings include:

Hospital Policy: Reference # (number) 1103
Subject: Staff Qualifications and Competency
No effective date documented

Policy:

...Jackson Medical Center (JMC) shall have in place a system to ensure that the licensure, registration and certification required for patient care staff is continually maintained.

JMC shall demonstrate, assess, maintain and improve staff competence on an ongoing basis.

...Procedure:

...The specific competencies required by the services provided and the department or unit scope...treatment provided....medications and equipment...

Staff shall have a documented competency assessment as part of the orientation, after the 90 (ninety) day orientation period and once every three (three) years or more...

Assessment methods include written exam, return demonstration, use of simulations...

1. ED PI # 7 presented to the ED on 1/1/23 at 7:09 AM with chief complaint possible seizure, was triaged at 8:00 AM and transferred via emergency transport on 1/1/23 at 11:01 PM.

Review of the ED record revealed on 1/1/23 at 9:43 PM, Propofol (Diprovan) 500 milligram (mg) /50 milliliter (ml), 2 ml/hr (hour) IV x (times) 1, was ordered, and administered.

MR review revealed documentation for a Diprovan (Propofol) protocol, signed by the ED physician and EI (Employee Identifier) # 18, ED RN (Registered Nurse), though no date/time was documented on the Diprovan protocol.

Review of the ED Nurse documentation dated 1/1/23 completed by EI # 19, ED RN revealed ED PI # 7's respiratory status and ventilator settings were monitored every 15 minutes from 9:45 PM till 11:30 PM.

Further ED record review revealed Nursing Note documentation dated 1/1/23 at 9:56 PM which revealed "...the physician was at bedside for intubation, 9:28 PM Etomidate 20 given IVP (intravenous push)... Roc (Rocuronium) 50 mg given...9:30 PM intubated per Dr (doctor)...9:37 PM bagging stopped and ventilator started. Diprovan drip started...At 10:27 PM dpirovan (Diprovan) increased...at 10:55 PM order received for roc 50 mg and given as ordered..."

Personnel record review revealed EI # 18's DOH (date of hire) was 5/20/16 and EI # 19's DOH was 5/24/18. There was no training and competency documentation for Diprovan preparation/administration and no competency documentation for care of a patient requiring mechanical ventilation.

In an interview conducted on 3/2/23 at 2:01 PM, the surveyor asked EI # 2, Chief Nursing Officer, which ED staff administered Etomidate, Rocuronium and Diprovan? EI # 2 reported the ED physician administered Etomidate and Rocuronium and ED RN's administered the IV sedative, Diprovan. The surveyor asked for ED staff training and competency documentation for Diprovan preparation/administration (prep/admin) and ventilator use.

There was no documentation ED staff were trained, and assessed competent to prep/admin IV Diprovan. There was no documentation the ED staff were assessed competent for care of a ventilator patient.

Based on hospital policy and procedure, medical record (MR) review, and staff interview it was determined the hospital failed to ensure Outpatient (OPT) physical therapy (PT) staff notified the ordering physician following an initial assessment/evaluation and obtained a telephone (verbal) order for the initial treatment plan per the hospital policy.

This affected Patient Identifier (PI) # 11, in one of one OPT PT record reviewed, and had the potential to affect all patients admitted for OPT PT.

Findings include:

Facility Policy: Patient Assessment and Reassessment-Rehabilitation Services
Reference # 8007
No approval/ effective/revised date documented

Policy:

Initial patient assessment and evaluation for benefits of Rehabilitation Services shall be performed on all patients referred to Rehabilitation Services by an ordering physician...

Procedure:

Evaluation of the patient by a licensed/Registered Rehabilitation Services professional may occur...

PT Assessment may include...

Based on an initial assessment and evaluation of the patient's physical, cognitive, support system...a rehabilitation treatment plan shall be developed...appropriate to the patient's needs... the treatment plan shall be documented in the patient's medical record....

Treatment Orders:

Call the physician to obtain a telephone order for treatment and write the treatment orders on the physician's order sheet. Include type, frequency and duration of the treatment...

1. PI # 11 was referred to hospital OPT Medicaid PT services on 1/9/23 to evaluate and treat for Cervilagia (neck pain).

Review of scheduling log documentation revealed due to patient illness, the PT assessment/evaluation was completed on 2/7/23 with PT treatments twice a week (wk) for four wk's for electrical stimulation, heat and therapeutic exercise.

There was no documentation the ordering physician was notified of PT plan including treatment type, frequency and duration.

In an interview conducted on 3/2/32 at 8:45 AM, Employee Identifier # 5, Doctor of Physical Therapy confirmed there was no documentation the ordering physician was notified of the initial assessment/evaluation treatment plan orders.