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Based on review of 2014 Governing Board Meeting Minutes, policy review, and interview, it was determined the facility failed to ensure the annual operating budget was approved by the Governing Board in two of two (March and July 2014) minutes reviewed. The failed practice did not ensure the Governing Board was aware of the facility's income and expenses and created the potential for inadequate funding to go unnoticed, which could affect any patient admitted to the facility. Findings follow.

A. Review of policy titled "Governing Body Responsibilities" stated "The Governing Board minutes include at least the following information: ...Review and approval of the hospital's annual operating budget and capital expenditure plan."
B. Review of biannual Governing Board Meeting Minutes for March and July 2014 revealed no evidence of the annual budget having been approved.
C. During an interview on 11/18/14 at 1245, the Administrator confirmed the operating budget had not been approved.

Based on 2014 QA (Quality Assurance) Meeting Minute review and interview, it was determined the facility failed to ensure contracted services were included in the QA program from January through October 2014. The failed practice did not ensure the Governing Board was responsible for all aspects of the facility and created the potential to affect any patient utilizing contracted services. Findings follow.

A. Review of 2014 QA Meeting Minutes revealed contracted services were not included in the QA program (ex: Environmental Services, Laboratory, Organ and Tissue Donation) from January through October 2014.
B. During an interview on 11/20/14 at 0845, the Director of Nursing confirmed contracted services were not included in the QA program.

Based on clinical record review and interview, it was determined the facility failed to ensure an Important Message from Medicare was provided to 25 of 25 (#6, #7, and #9-#30) Medicare patients prior to discharge from the facility. The failed practice created the potential for patients to be uninformed of their rights and could affect any Medicare patient admitted to the facility. Findings follow.

A. Review of closed clinical records revealed 25 of 25 (#6, #7, and #9-#30) Medicare patients did not receive an Important Message from Medicare within two days prior to discharge.
B. During an interview on 11/21/14 at 1150, the Biller/Coder confirmed the notice was not given prior to discharge.

Based on interview, clinical record review and policy and procedure review, it was determined of the 30 clinical records reviewed with patient photographs, the nursing staff failed to protect the personal privacy and dignity for five (#8, #15, #22, #24 and #27) of five (#8, #15, #22, #24 and #27) patients in that unnecessary photographs were taken of the patient's genital and buttocks area which was not in accordance with policy to document progress of medical treatment; failed to protect the patient's privacy by allowing a non-clinical employee access to a camera that had 841 photographs of multiple patient's bodies and could be viewed. The failed practice did not afford the basic right of personal privacy for Patients #8, #15, #22, #24 and #27. Findings follow:

A. Review of the policy and procedure titled "Use of Photography for Documentation" received from the Director of Nursing (DON) at 1230 on 11/21/14 revealed the purpose was "To document the progress of medical treatment OR for education and training." The procedure included: "...#4 Remove wound dressing (if applicable) position and drape the patient and place a disposable measuring tape next to the wound (written documentation of wound measurements is also acceptable). ...#10 Re-dress wound (if applicable) ...#12. Print photographs then delete from camera memory."
B. Observation at 1125 on 11/21/14 of the camera used by the nursing staff to take patient photographs revealed there were 841 photographs that dated back to July of 2014. During an interview with the DON at 1110 on 11/21/14, he stated the photographs should be deleted after a week. The DON verified the number of photographs during this interview. The camera contained photographs of a laryngoscope. The DON was asked during the interview why the laryngoscope photographs were on the camera. The DON stated the laryngoscope bulb needed replacing and the Administrative Coordinator took photographs of the laryngoscope to order the correct part. The DON verified the Administrative Coordinator was not clinical and had access to the camera with the photographs of patients and their various body parts and regions.
C. Review of the photographs for Patients #8, #15, #22, #24 and #27 revealed no indication of the medical treatment that warranted the photographs of the genital and rectal regions. The photographs taken of Patients #8, #15, #22, #24 and #27 totaled 14.
D. During an interview with the DON from 1100 to 1125 on 11/21/14 (in the presence of Surveyors #1 and #2), Surveyor #3 and the DON reviewed the photographs for Patients #8, #15, #22, #24 and #27. The DON agreed with Surveyor #3 that the photographs were unnecessary.

Based on review of employee files and interview, it was determined the facility failed to have a policy/procedure to screen potential employees for a history of criminal/abusive behavior and failed to obtain Criminal Background Checks (CBC) on 11 of 11 (Physical Therapists #1 and #2, Physical Therapist Assistants #1 and #2, Occupational Therapists #1 and #2, Certified Occupational Therapy Assistants #1 and #2 and Speech Therapists #1-3). By not having a policy/procedure for obtaining CBC, the facility could not assure they were hiring someone without a history of abusive behavior. The failed practice had the potential to affect all patients who receive Therapy. Findings follow:

A. Review of Physical Therapists #1 and #2, Physical Therapist Assistants #1 and #2, Occupational Therapists #1 and #2, Certified Occupational Therapy Assistants #1 and #2 and Speech Therapists #1-3 employee file revealed there was CBC in their file.
B. During an interview on 11/19/14 at 1300, the Administrator verified the facility did not have a policy or procedure in place to screen potential employees and verified there were no CBCs in the 11 Therapists'/Aides' employee files.

Based on policy review, 2014 Governing Board Meeting Minutes review, and interview, it was determined the facility failed to ensure the Governing Board dictated the specifics of the QA (Quality Assurance) projects to be implemented in the facility in two of two (March and July 2014) minutes reviewed. The failed practice did not ensure the Governing Body assumed full responsibility of the QA program and had the potential to affect any patient admitted to the facility. Findings follow.

A. Review of policy titled "Delivery of Services-Quality Assessment & Improvement" stated "The Governing Body assumes overall responsibility and accountability for the organization-wide QA/PI program. The Governing Body, Chief Executive officer and Medical Staff shall ensure QA/PI activities, address identified priorities and be responsible for the development, implementation, monitoring and documentation of improvement activities."
B. Review of the QA plan and biannual Governing Board Meeting Minutes (March and July 2014) revealed no evidence the Governing Board had approved the QA program indicators and data collection frequency.
C. During an interview on 11/20/14 at 0845, the Director of Nursing confirmed the Governing Board did not approve specific QA indicators.

Based on review of 2014 Quality Assurance Meeting Minutes and interview, it was determined the facility failed to track and trend medication errors for January through October 2014. The failed practice did not allow the facility to identify causes of errors and therefore implement policies and procedures to decrease future errors. The failed practice had the potential to affect any patient in the facility. Findings follow.

A. Review of 2014 Quality Assurance Meeting Minutes for January through October 2014 revealed no evidence of tracking medication errors.
B. During an interview on 11/20/14 at 0925, the Pharmacist and the Administrator confirmed medication errors were not tracked and trended.

Based on 2014 QA (Quality Assurance) Meeting Minutes review and interview, it was determined the facility failed to ensure contracted services were included in the QA program from January through October 2014. The failed practice did not ensure the Governing Board was responsible for all aspects of the facility and created the potential to affect any patient utilizing contracted services. Findings follow.

A. Review of 2014 QA Meeting Minutes for January through October 2014 revealed contracted services were not included in the QA program (ex: Environmental Services, Laboratory, Organ and Tissue Donation).
B. During an interview on 11/20/14 at 0845, the Director of Nursing confirmed contracted services were not included in the QA program.

Based on review of 2014 Governing Board Meeting Minutes, policy review, and interview, it was determined the facility failed to ensure the QA/PI (Quality Assurance/Performance Improvement) plan was approved by the Governing Board in tow of two (March and July 2014) minutes reviewed. The failed practice did not ensure the Governing Board was responsible for the Quality Assurance activities being conducted in the facility. Findings follow.

A. Review of policy titled "Governing Body Responsibilities" stated "The Governing Board minutes include at least the following information: ...Review and approval the Quality Assurance/Performance Improvement (QA/PI) plan of the facility, at least annually ..."
B. Review of policy titled "Delivery of Services-Quality Assessment & Improvement" stated "The PIP (Performance Improvement Plan) is reviewed and approved by the Chief Executive Officer, the Medical Staff and the Governing Body annually."
C. Review of the biannual Governing Board Meeting Minutes for March and July 2014 revealed no evidence of the QA/PI plan had been approved.
D. During an interview on 11/18/14 at 1245, the Administrator confirmed the QA/PI plan had not been approved.

Based on interview, review of policies and procedures and job descriptions, it was determined the facility failed to ensure that nursing personnel with the appropriate education, experience, licensure and competence were allowed to insert and maintain Foley catheters and maintain central venous catheters. Failure to ensure staff was competent by education, experience or competency checks did not allow the facility to ensure patients received care from competent and knowledgeable staff. The failed practice affected all one of one (#31) patient whose care required a central venous line. Findings follow:

A. Review of the policies and procedures for Catheterization and Central Venous Lines as well as the job descriptions for Registered Nurses and Licensed Practical Nurses revealed no statements addressing which staff was qualified and how they were qualified to perform care and maintenance.
B. The above findings were verified by the Director of Nursing at 1030 on 11/20/14.

Based on review of clinical records, review of policy and interview, it was determined the facility failed to have medical history and physical (H&P) examinations completed and documented no more than 30 days before or 24 hours after admission or registration in six (#11, 17, 19, 21 and 22) of 30 (#1-30) patients. By not having the information in the chart, the facility could not assure the patients' course of treatments were not compromised by the lack of information. The failed practice had the likelihood to affect all patients. Findings follow:

A. Review of clinical records revealed the following:
1) Patient #11 was admitted on 08/01/14; The H&P was dictated on 08/03/14 and transcribed 08/04/14;
2) Patient # 17 was admitted on 08/26/14; The H&P was dictated on 09/14/14 and transcribed on 09/15/14;
3) Patient # 19 was admitted on 08/21/14; The H&P was dictated on 08/25/14 and transcribed on 08/27/14;
4) Patient # 21 was admitted on 09/01/14; The H&P was dictated on 09/03/14 and transcribed on 09/03/14;
5) Patient # 22 was admitted on 09/01/14; The H&P was dictated on 09/03/14 and transcribed on 09/03/14; and
6) Patient # 30 was admitted on 11/07/14; The H&P was dictated on 11/09/14 and Transcribed on 11/10/14.
B. Review of policy titled "Orders & Evaluation" stated "Complete and transcribed H&P on all patients within twenty-four (24) hours of admission. The H&P must be on the chart either handwritten or transcribed and in the patient's medical record with 24 hours of admission."
C. During an interview on 11/21/14 at 1155, the Director of Nursing verified the H&Ps were not in the clinical record within the 24 hour timeframe.

Based on observation, review of policies and interview, it was determined the Pharmacist failed to assure there was a policy or procedure in place that addressed patients being dispensed their own home medications in that one (#2) of five (#1, 3-5) patients had a home medication being administered to her. By not having a policy or procedure in place that addressed the use of home medications, the facility could not assure the safety and accuracy of the medication being administered from the container being brought from home. The failed practice had the likelihood to affect every patient that brought their home medications to be administered to them that is not verified by the pharmacist prior to administering. Findings follow:

A. During a tour of the nursing unit on 11/20/14 at 0930, observation revealed a home medication in the medication cart for Patient #2. The medication was labeled Captopril 50 milligrams, give 2 tablets twice a day.
B. Review of Pharmacy polices on 11/20/14 at 1000 revealed there was not a policy on what to do with home medications to be administered.
C. During an interview on 11/20/14 at 0930 with Registered Nurse #1, the nurse verified there was a home medication for patient administration in the medication cart.
D. On 11/20/14 at 1115, the Administrator was asked for a policy on administering home medications. At the time of exit on 11/21/14 at 1215, Surveyor #1 had not received one.

Based on interview, the supervising pharmacist failed to assure policies and procedures were in place for annual re-certification of Intravenous (IV) Admixture technique for all personnel trained to compound medications in the Laminar Flow Hood (per United States Pharmacopeia Chapter 797, 2008). By not evaluating the competencies of the personnel, the facility could not assure the sterility or accuracy of the medications compounded. The failed practice had the likelihood to affect all patients who received medications compounded in the Laminar Flow Hood. Findings follow:

A. IV Admixture competencies were requested at the entrance conference on 11/18/14 and Surveyor #1did not receive any.
B. During an interview on 11/19/14 at 1400 the Director of Pharmacy verified they did not have competencies, policies or procedures for annual competencies (ie: media fill tests or take samples of finished products and have them tested for sterility) of the personnel trained to compound medications in the Laminar Flow Hood.

Based on review of incident reports, Pharmacy and Therapeutics Committee Meeting Minutes, review of policy and interview, it was determined the facility failed to notify the practitioner who ordered the medication of the medication errors for 7 of 12 medication errors as identified in Incident Reports from 05/29/14 to 10/01/14 and failed to fill out medication error forms for 8 of 8 medication errors identified in Pharmacy and Therapeutic Committee Meeting Minutes from 01/01/14 to 09/30/14. By not filling out medication error forms and not reporting medication errors to the prescribing physician responsible for the patient's care, the patient's physicians were not being kept abreast of the patient's condition and were not involved in the decisions of what to do after the error occurred. The failed practice had the potential to affect all patients. Findings follow:

A. Review of Incident Reports on 11/18/14 at 1450 revealed 12 medication errors dated between 05/29/14 and 10/01/14. Of the 12 errors, 7 were not reported to the physician.
B. Review of Pharmacy and Therapeutics Committee Meeting Minutes for the previous 3 quarters (01/01/14 through 09/30/14) revealed eight medication errors. Medication error forms were not filled out for these errors, nor were the physicians notified of the errors. The errors were discovered upon cart return to the pharmacy. For example, if a patient's cart was returned with extra Potassium tablets in it, The Director of Pharmacy stated he would check the Physician order or the Medication Administration Record and see if it was only given once a day when it should have been twice.
C. Review of policy titled Pharmacy: Medication Errors, Adverse Reactions & Drug Incompatibility on 11/18/14 at 1310 stated "Medication errors will be reported to the Attending Physician." The policy also stated "The party that discovers the medication error is ultimately responsible (either nursing or pharmacy) for completing the medication error form."
D. During an interview on 11/20/14 at 0925, the Administrator and the Director of Pharmacy verified the medication errors that were not reported to the physicians and the medication errors that did not have a medication error form completed.

Based on Policy and Procedure Manual review and interview, it was determined the facility failed to procure a contract for the preventative maintenance of patient care medical equipment equipment. The failed practice had the potential to affect the health and safety of all patients because the safety and reliability of the equipment was not monitored or tested by qualified personnel. The facility had a census of seven patients on 11/24/14. The findings follow:

A. Review of the Policy and Procedure Manual on 11/24/14 at 1315 revealed Policy 08-01-01 required "A Preventative Maintenance Plan and a Safety Committee oversee the safety of the physical plant, the utility systems, and the electrical powered patient equipment. Maintenance staff is provided through contract with CMH (Chicot Memorial Hospital)."
B. In an interview on 11/24/14 at 1320, the Administrative Coordinator verified the patient care equipment was not under a contract for preventative maintenance, and she periodically checked the equipment for frayed cords and general operation.
C. In an interview on 11/24/14 at 1330, the Administrator verified the patient care equipment was not inspected by qualified personnel through a contracted service.

Based on interview and policy and procedure review, it was determined the facility failed to ensure the Infection Preventionist was qualified by education, training, experience or certification; did not follow its policy in that cleaning supplies were not annually approved by the Infection Control Committee; and did not have policies and procedures in place to address infection control components during the construction, renovation, maintenance and repair of the facility. Failure to ensure the Infection Preventionist was qualified did not allow the facility to be assured and confident that a current and proactive Infection Control Program was developed, maintained and adjusted per the facility's infection characteristics. Failure to annually approve the cleaning supplies did not ensure the facility had researched and chosen cleaning supplies effective for its infection population. Failure to have in place infection control policies, procedures or mechanisms outlining safety needs during construction, repair or remodeling did not allow the facility to be assured of the safety of patients, staff and visitors. The failed practices affected all patients in the facility. Findings follow:

A. During an interview with the Director of Nursing (DON) at 1000 on 11/20/14, he verified he had not been to any infection control training or educational events. The DON stated when he assumed the DON position; he also assumed the Infection Preventionist, Employee Health, Quality Assurance, Discharge Planning and Safety roles. Review of the DON's personnel file supported the above.
B. Review of the policy and procedure titled "Infection Control Committee" received from the DON at 1020 on 11/20/14 revealed the following: "under #4. Annually review and approve all products used throughout the facility (maintain an approved list) relative to disinfection, decontamination, sanitation and/or sterilization and approve all interim changes. Under #7. Approve a list of all agents for cleaning and disinfecting to be used in the facility." Review of the policy and procedure titled "Delivery of Services - Infection Control and Employee Health" last paragraph of the first page stated " ...Infection Control maintains a list of approved disinfectants, antiseptics and germicides and their approved use in SRH (facility)." The list of cleaning products received from the DON at 1030 on 11/20/14 were not approved per policy and procedure. The above findings were verified by the DON at 1030 on 11/21/14.
C. By the end of the exit conference at 1215 on 11/21/14 no policies, procedures or mechanisms addressing infection control during construction, repair or remodeling of the building had been presented as requested at 1030 on 11/20/14.

Based on interview, observations and review of policy and procedures, it was determined the facility failed to show evidence of coordination with federal, state and local emergency officials for communicable disease threats, bioterrorism and outbreaks; failed to follow policy and procedure and the manufacturer's guidelines in the cleaning a blood gluocose monitoring device after use on one of one (#4) patient observed; and failed to follow policy and procedure for performing hand hygiene between a dirty and clean task for one of one (#31) patient observed. Failure to coordinate with federal, state and local emergency officials for communicable disease threats, bioterrorism and outbreaks, did not allow the facility to be prepared and proactive in the event of any of the above. Failure to clean blood glucose monitoring device per manufacturer's guidelines and perform hand hygiene when moving from a dirty to sterile area had the potential to allow for contamination and infection of a PICC (peripherally inserted central catheter) . Failure to coordinate with outside agencies had the potential to affect all patients, staff and the community. Failure to clean equipment had the potential to affect all patients requiring the use of a glucometer and failure to remove gloves and wash hands prior to moving to the central line affected Patient #31. Findings follow:

A. During an interview with the Director of Nursing (DON) at 1020 on 11/20/14, he was asked for evidence the facility had coordinated or planned mechanisms in the event of a local outbreak, bioterrorism event or other infectious illness. By the end of the exit conference at 1215 on 11/21/14 no evidence had been presented.
B. During the delivery of care to Patient #4 at 1115 on 11/19/14 Licensed Practical Nurse (LPN) #1 was observed to not clean the glucometer after checking Patient #4's blood sugar. The glucometer was put back in the drawer of the medication cart without cleaning. Review of the manufacturer's guidelines revealed the following: " ...using this system on multiple patients should follow the infection control procedure approved by their facility. All products or objects which come in contact with human blood, even after cleaning, should be handled as if capable of transmitting viral diseases." Review of the policy and procedure titled "Delivery of Services-Physical Environment Equipment" received from the DON at 1030 on 11/20/14 revealed no mention specifically regarding cleaning of a glucometer but second paragraph stated "All patient care items and equipment will be cleaned and sterilized between use for different patients if disposable items are not utilized."
C. During the delivery of care to Patient #31 at 1155 on 11/19/14 Registered Nurse (RN) #2 was observed to don gloves without washing hands first, then raised the lid of the dirty bedside commode, swing Patient #31's feet and legs to the floor (dirty task) and then attempted to remove the IV (intravenous) tubing from the PICC (clean task) located in the right arm. RN #2 then cleaned the port with alcohol, flushed and capped off the PICC (clean task) so Patient #31 could be moved to the bedside chair per her request. RN #2 did not perform hand hygiene or change gloves after completing a dirty task and before a clean task was initiated. RN #2 verified her actions at 1220 on 11/19/14.



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Based on observation, review of policy and interview, the facility failed to maintain six (parallel bars, two hand cycles and three assistive devices) pieces of therapy equipment and two bed side tables in a manner that prevented them from being thoroughly cleaned to prevent cross contamination between patient use in the rehabilitation gym; the equipment and one bedside table had sticky duct tape/residue (not able to sanitize) and a table with rust and chipped Formica (porous and not able to sanitize). By not maintaining therapy equipment in a way that allowed them to be thoroughly cleaned, the facility could not assure the sanitary environment when patients used these items. The failed practice had the likelihood to affect all patients that receive therapy services in the rehabilitation gym. Findings follow:

A. During a tour of the rehabilitation gym on 11/20/14 at 1010, observation revealed the following:
1) Red duct tape on the parallel bars, 2 hand cycles, 3 walking assistive devices and wrapped around a bedside table; and
2) A bedside table used during therapy had a large amount of rust on the stand and had Formica missing in places on the top with the fibers of the particle board exposed.
B. Review of policy titled Physical Environment: Equipment stated "[Facility name] equipment shall be maintained in a manner that is safe, clean and in good repair to ensure the safety and well-being of the patients."
C. During an interview on 11/21/14 at 1015, Physical Therapist #1 verified the red tape on the equipment, rust and chipped Formica on the bedside table.

Based on review of List of Contracted Venders and interview, it was determined the facility failed to have a written agreement with an Organ Procurement Organization (OPO). By not having a current contract with an OPO, the facility could not assure that families of individuals whose death was imminent or died in the hospital would be made aware of their options to donate or decline to donate organs or tissues. The failed practice had the likelihood to affect all individuals whose death is imminent or died in the hospital. Findings follow:

A. Review of List of Contracted Venders (as of 08/29/14) revealed there was not a contract with an OPO.
B. The Administrator was asked for a copy of the current contract with an OPO during the entrance conference on 11/18/14 at 1030, on 11/19/14 at 1130 and on 11/19/14 at 330.
C. During the exit conference on 11/21/14 at 1215, the Administrator verified a contract was never provided.

Based on review of employee files, review of policy and interview, it was determined the facility failed to ensure one (#1) of two (#1 and 2) Physical Therapy Assistants (PTA)maintained certification in Cardiopulmonary Resuscitation (CPR) per policy. By not ensuring all persons with direct patient care responsibilities maintain certification in CPR, the facility could not assure a prompt and efficient response in the event of an emergency. The failed practice had the likelihood to affect all patients who received services from PTA #1. Findings follow:

A. Review of employee files on 11/19/14 revealed PTA #1 did not have CPR certification.
B. Review of policy titled CPR stated "Each staff member of [facility named] who provides direct patient services is required to maintain certification in CPR as outlined in the standards of the American Heart Association."
C. During an interview on 11/19/14 at 1310, the Director of Nursing verified PTA #1 did not have CPR certification.

Based on review of the Policy and Procedure Manual, it was determined the facility failed to develop policies and procedures defining the assembly, operation and maintenance of respiratory care equipment when used by non-respiratory staff. Failure to develop policies or procedures did not allow the non-respiratory staff performing respiratory care and treatments to have access to how equipment was assembled for use, operated, cleaned or what to do if the equipment malfunctioned. The failed practice had the likelihood to affect all patients who receive respiratory treatments from non-respiratory staff. Findings follow:

A. Review of the Policy and Procedure Manual received from the Director of Nursing at 1200 on 11/18/14 revealed it did not contain policies and procedures defining the assembly, operation and maintenance of respiratory care equipment.
B. By close of the exit conference conducted at 1215 on 11/21/14 no policies or procedures for the assembly, operation and maintenance of respiratory care equipment had been presented.

Based on review of the Policy and Procedure Manual, it was determined the facility failed to develop policies and procedures defining the qualifications, including job titles, licensure, education and training of the personnel authorized to perform each type of respiratory care service. Failure to develop policies and procedures which defined licensure, training and education of the staff administering respiratory services did not ensure patients were receiving respiratory treatments from qualified, competent staff. The failed practice had the likelihood to affect all patients who receive respiratory services. Findings follow:

A. Review of the Policy and Procedure Manual received from the Director of Nursing at 1200 on 11/18/14 revealed it did not contain any policies and procedures defining which disciplines were considered qualified to perform respiratory services based on education, training and/or experience.
B. By close of the exit conference conducted at 1215 on 11/21/14 no policies or procedures had been presented defining which disciplines were considered qualified to perform respiratory services based on education, training and/or experience.