HospitalInspections.org

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.

Findings include:

Refer to Life Safety Code violations.

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

1. Follow the policy for Hepatitis B immunization.

2. Follow the policy for tuberculosis skin testing.

3. Follow the policy for competency requirements for employees.

4. Conduct annual performance evaluations.

5. Complete an orientation checklist for each employee.

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

Findings include:

Policies and Procedures
Subject: Employee Health
Reviewed: 2/13

"Philosophy:

Wedowee Hospital recognizes its responsibility for prevention of disease transmission and the promotion of optimum health by establishing and maintaining an employee health program based on principles of infection prevention and health maintenance...

Employee Health Procedure:

a. A pre-employment health history is obtained and maintained in their personnel file.
b. A Tuberculosis Skin Testing program for new employees adheres to the policies of the State Health Department. New employees have a PPD (Purified Protein Derivative) upon hire. These are repeated annually. If the employee is sensitive to the PPD, then a chest x-ray is obtained...
c. The employee upon hire is counseled on the risks of exposures to bloodborne pathogens and the benefits of receiving the Hepatitis B vaccine. The vaccine is then offered to the employee at no charge. If the employee decides to be vaccinated at anytime during employment, the vaccine will be given at no charge to the employee..."

Policies and Procedures
Subject: Competency Requirement for Employees
Issued: 5/12/98

"Policy:

Wedowee Hospital will define competency requirements for employment and continued employment at Wedowee Hospital. Department Managers are responsible for assuring competency of all personnel as appropriate for the job responsibilities. Competency is defined as demonstration through individual qualifications, continuing education and performance of tasks/skills of the individual's ability to perform the essential functions of the job.

Each employee is required to demonstrate competency for continued employment as appropriate for the essential job responsibilities in accordance with the standards established by the Department Manager...

Procedure:

Responsibility: Department Head

Action: Indicates review of employee's competencies at the end of six months employment and annually thereafter. Documents competencies in department files..."

Policies and Procedures
Subject: Performance Evaluation

Policy:

"An employee of Wedowee Hospital will receive a performance evaluation upon completion of the initial employment period, annually during common review cycle and at the time of employee's promotion, demotion or transfer to another job..."

Review of select employee personnel files including regular employees, contract employees, and advance practice nurses revealed:

1. 2 of 30 files reviewed failed to show documentation of a current tuberculosis screening.
2. 5 of 30 files reviewed failed to show documentation the employee received Hepatitis B vaccine or signed the declination.
3. 15 of 17 employee files reviewed failed to show documentation of competency skills on hire or annually thereafter.
4. 15 of 17 employee files reviewed failed to show documentation an annual performance evaluation was performed.
5. 15 of 17 employee files reviewed failed to show documentation orientation had been completed.

Written questions were submitted 6/11/15 at 1:15 PM to Employee Identifier # 1, Director of Support Services, and answers were received via facsimile on 6/12/15 at 7:46 AM, with the aforementioned findings verified.

Based on review of hospital policies and procedures and staff interviews it was determined the facility failed to provide a Quality Assurance and Performance Improvement (QAPI) program to include:

1. Indicators to identify and reduce medical errors.

2. A process for staff to report blood transfusion reactions and reviews of reported blood transfusion reactions to identify medical errors.

This had the potential to affect every patient served by the hospital.

Findings include:

Wedowee Hospital Policy and Procedures
Subject: Quality Assurance and Performance Improvement (QAPI) Program

Purpose:

To maintain an effective, ongoing, hospital-wide, data-driven quality assurance and performance improvement program at Wedowee Hospital. The program will involve all hospital departments and services, including those services furnished under contract or arrangement. This program will focus on measurable indicators related to improving health outcomes and the prevention and reduction of medical errors.

Policy:

"The hospital shall measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service, and operations. The program shall incorporate quality indicator data including patient care data and other relevant data and use the data collected to:

1. Monitor the effectiveness and safety of services and quality of care.
2. Identify opportunities for improvement and changes that will lead to improvement in the safety of services and the quality of care...

Program Activities:

B. Performance improvement and quality assurance activities shall track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital...

Executive Responsibilities:

The hospital's governing authority, medical staff, and administrative officials are accountable for ensuring the following:

(a) That an ongoing program for quality improvement and patient safety, including the reduction of medication errors, is defined, implemented and maintained.
(b) That the hospital-wide QAPI efforts address priorities for improved quality of care and patient safety; and that all improvement actions are evaluated...
(e) That the determination of the number and distinct improvement projects is conducted annually..."


During review of the QAPI program and completion of the CMS (Centers for Medicare and Medicaid Services) QAPI Worksheet, it was determined that the pharmacist monitored and tracked medication errors but failed to report them as a part of the hospital-wide QAPI program.

It was further determined that blood transfusion reactions were reviewed with the medical staff, but were not reported to or included in the hospital-wide QAPI program.

An interview was conducted 6/10/15 at 1:50 PM with Employee Identifier (EI) # 4, Quality Assurance/Infection Control Coordinator, who confirmed the aforementioned findings.

Based on review of hospital policy and procedures and staff interviews it was determined the governing body failed to ensure:

1. The Quality Assurance and Performance Improvement (QAPI) program:

(a) Included indicators to identify and reduce medical errors.
(b) Included a process for staff to report blood transfusion reactions and reviews of reported blood transfusion reactions to identify medical errors.
(c) Encompassed all hospital departments and services.

2. The number of distinct improvement projects to be conducted annually was determined.

3. Approve the improvement projects included in the QAPI program.

This had the potential to affect every patient served by the hospital.

Findings include:

Wedowee Hospital Policy and Procedures
Subject: Quality Assurance and Performance Improvement (QAPI) Program

Purpose:

To maintain an effective, ongoing, hospital-wide, data-driven quality assurance and performance improvement program at Wedowee Hospital. The program will involve all hospital departments and services, including those services furnished under contract or arrangement. This program will focus on measurable indicators related to improving health outcomes and the prevention and reduction of medical errors.

Policy:

"The hospital shall measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service, and operations. The program shall incorporate quality indicator data including patient care data and other relevant data and use the data collected to:

1. Monitor the effectiveness and safety of services and quality of care.
2. Identify opportunities for improvement and changes that will lead to improvement in the safety of services and the quality of care...

Program Activities:

B. Performance improvement and quality assurance activities shall track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital...

Executive Responsibilities:

The hospital's governing authority, medical staff, and administrative officials are accountable for ensuring the following:

(a) That an ongoing program for quality improvement and patient safety, including the reduction of medication errors, is defined, implemented and maintained.
(b) That the hospital-wide QAPI efforts address priorities for improved quality of care and patient safety; and that all improvement actions are evaluated...
(e) That the determination of the number and distinct improvement projects is conducted annually..."


During review of the QAPI program and completion of the CMS (Centers for Medicare and Medicaid Services) QAPI Worksheet, it was determined that the pharmacist monitored and tracked medication errors but failed to report them as a part of the hospital-wide QAPI program, and blood transfusion reactions were reviewed with the medical staff, but were not reported to or included in the hospital-wide QAPI program.

This surveyor asked the question whether or not the QAPI program had been presented to the governing body for approval, and was informed that it had not been approved.

An interview was conducted 6/10/15 at 1:50 PM with Employee Identifier (EI) # 4, Quality Assurance/Infection Control Coordinator, and EI # 5, Nursing Consultant, who confirmed the aforementioned findings.

Based on a tour of the Medical Records Department it was determined that the facility failed to provide proper storage for all current medical records being kept at the facility. This had the potential to negatively affect all patient records being stored at this facility.

Findings include

A tour of the Medical Record Department was conducted on 6/11/15 at 8:45 AM with Employee Identifier # 1, Director of Support Services. During the tour the surveyor was taken to the medical record storage room. Prior to entering the storage room a fire extinguisher was hanging on the wall outside of the medical record storage area.

In the storage area were multiple patient charts that were being held until proper date of destruction.

During an observation of the medical record storage room it was determined the storage room was lacking a sprinkler system and the medical records were not protested from fire, water damage and other threats.

An interview was conducted on 6/11/15 at 9:10 AM with EI # 1, who confirmed there was not a sprinkler system in the medical record storage area.

Based on review of hospital policy and procedures and staff interviews it was determined pharmacy personnel failed to ensure indicators to identify and reduce medical errors were reported to the Quality Assurance/Infection Control Coordinator to be included in reports to the governing body.

This had the potential to affect every patient served by the hospital.

Findings include:

Wedowee Hospital Policy and Procedures
Subject: Quality Assurance and Performance Improvement (QAPI) Program

Purpose:

To maintain an effective, ongoing, hospital-wide, data-driven quality assurance and performance improvement program at Wedowee Hospital. The program will involve all hospital departments and services, including those services furnished under contract or arrangement. This program will focus on measurable indicators related to improving health outcomes and the prevention and reduction of medical errors.

Policy:

"The hospital shall measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service, and operations. The program shall incorporate quality indicator data including patient care data and other relevant data and use the data collected to:

1. Monitor the effectiveness and safety of services and quality of care.
2. Identify opportunities for improvement and changes that will lead to improvement in the safety of services and the quality of care...

Program Activities:

B. Performance improvement and quality assurance activities shall track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital...

Executive Responsibilities:

The hospital's governing authority, medical staff, and administrative officials are accountable for ensuring the following:

(a) That an ongoing program for quality improvement and patient safety, including the reduction of medication errors, is defined, implemented and maintained.
(b) That the hospital-wide QAPI efforts address priorities for improved quality of care and patient safety; and that all improvement actions are evaluated...
(e) That the determination of the number and distinct improvement projects is conducted annually..."


During review of the QAPI program and completion of the CMS (Centers for Medicare and Medicaid Services) QAPI Worksheet, it was determined that the pharmacist monitored and tracked medication errors but failed to report them as a part of the hospital-wide QAPI program.

An interview was conducted 6/10/15 at 1:50 PM with Employee Identifier (EI) # 4, Quality Assurance/Infection Control Coordinator, and EI # 5, Nurse Consultant, who confirmed the aforementioned findings.

Based on a tour of the Dietary Department it was determined the department failed to monitor the temperatures of the low temperature dish washing machine and labeling of all food products with content and date opened. This had the potential to negatively affect all patients served by the facility.

findings include

Policy: Dish Machine Washing Dishes
Policy Revised Date: 2/1/10

Purpose:

To prevent the spread of bacteria that may cause food borne illnesses.

Standard:

Dish machines should be operated in accordance with manufacture's instructions, in order to promote sanitation of dishes and utensils.

Process:

1. Dish machines using chemicals for sanitization (also called low temperature machines), may be used if the temperature of the wash/rinse water meets manufacture's recommendations (or state and local guidelines if more stringent). Low temperature machines generally require the wash tank temperature to be a minimum of 120 degrees F (Farenheit) and the rinse tank temperature to be a minimum of 120 degrees F.

3. Dish machine wash and rinse temperatures should be recorded before each dishwashing cycle and checked periodically during the dishwashing process.

4. Dish machine chemical concentration on low temperature machines should be monitored and generally require a minimum of 50 ppm (parts per million) of a hypochlorite solution on dish surface in final rinse.

A tour was conducted on 6/9/15 at 1:00 PM with Employee Identifier (EI) # 2, Dietary Manager.

During the tour the surveyor asked for the temperature log for the dishwasher. EI # 2 stated temperatures are not recorded and the staff observes the thermometer to ensure the correct temperature.

During the tour the surveyor observed 1 large container of Decaffeinated Tea, 1 large container of Marinate, 1 large container of dried macaroni and 1 large jug of cooking oil which did not contain a label with the contents and date it was opened.

Further observation of the freezers revealed there was 3 large plastic bags of chicken tenders, 2 large bags of chicken breasts, 2 bags of meatballs, 3 bags of carrot sticks and 6 bags of smoked sausage in the freezer without a label of contents and date opened.

Observation of the refrigerator revealed half a ham and smoked sausage each in its own plastic bag with no label of the contents or date opened.

An interview was conducted at 2:30 PM with EI # 2, who confirmed the above mentioned findings and agreed all items are to be labeled with the contents and the date it was opened.

Based on facility policy, observations and an interview with the staff it was determined Employee Identifier (EI) # 3, the cook, failed to follow agency policy for infection control and handwashing. This had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Handwashing

Purpose:

To prevent transmission of infections in the hospital

Policy:

Employees should wash their hands, (but will not limit it to) each time they exit the kitchen then re-enter the kitchen or change duties.

A tour was conducted on 6/10/15 at 11:00 AM to observe plating of the patient food trays. While observing, the surveyor was told Employee Identifier # 3 would also be plating the patient food.

During the observation while EI # 3 was plating food EI # 3 walked over to the refrigerator, opened it and removed a carton of milk and placed it on the cart. EI # 3 failed to remove gloves, sanitize hands and don new gloves before continuing with the plating of the food.

EI # 3 placed all food containers on a cart to be transported to the patient area. Prior to leaving the dietary area EI # 3 failed to remove gloves and sanitize hands.

An interview was conducted on 6/11/15 at 9:00 AM with EI # 2, Dietary Manager, who confirmed the above mentioned findings and stated EI # 3 should have removed gloves and sanitized hands prior to leaving the dietary department and EI # 3 should have removed gloves and sanitized hands after opening the refrigerator.

Based on review of medical records (MR) and interview it was determined the facility failed to ensure all outpatient procedures had a documented history and physicial (H&P) completed 30 days prior or 24 hours after admission for scheduled procedure.

This affected MR # 9, MR # 10, MR # 11, MR # 12, MR # 13, and MR # 22, 6 of 8 outpatient records reviewed and had the potential to affect all patients admitted to the facility for outpatient services.

Findings include:

1. Review of MR # 9 revealed the patient was admitted for a Colonoscopy 6/10/15 . There was no H&P contained in the MR

2. Review of MR # 10 revealed the patient was admitted for a Esophagogastroduodenoscopy (EGD) and Colonoscopy 3/19/15 . There was no H&P contained in the MR.

3. Review of MR # 11 revealed the patient was admitted for a Colonoscopy 4/30/15 . There was no H&P contained in the MR.

4. Review of MR # 12 revealed the patient was admitted for a Colonoscopy 5/14/15 . There was no H&P contained in the MR.

5. Review of MR # 13 revealed the patient was admitted for a Colonoscopy 8/07/14 . There was no H&P contained in the MR.

6. Review of MR # 22 revealed the patient was admitted for aEGD 6/11/15 . There was no H&P contained in the MR.

An interview conducted 6/11/15 at 10:30 with Employee Identifier # 5, Nursing Consultant, verified there were no H&P,s in the above records reviewed.