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. This had the potential to affect all patients served by the hospital.

Findings include:

Refer to Life Safety Code violations for findings.

Based on medical record review, policy and procedure review and interviews with administrative staff, the hospital failed to ensure there were physician's orders for the use of restraints. This affected 1 of 1 (MR # 10) record reviewed with restraints and had the potential to affect all patients served by the hospital.

The findings include:

Policy:
Restraint of Patient,
Date Revised: 8-12-13
Number: 118.26

"IV. Policies: A ... The attending physician will be notified within 12 hours of the initiation of the protocol and will sign the original protocol order within 24 hours of implementation ...
V. Procedures:
A. Restraint types: ... 3. Body Holder (Body holders are used if vest restraint is ordered) ... "

1. MR # 10 was admitted on 2/1/14 with diagnoses to include Pyelonephritis and Dehydration.

A review of MR # 10's medical record revealed there was no order for the restraint used on 2/4/14.

The 2/4/14 nurse note documented MR # 10 was restrained at 18:35 (6:35 PM) with a vest restraint. The activity documented was agitation.

The 2/4/14 nurse note documented MR # 10 was restrained at 18:42 (6:42 PM) with a vest restraint. The activity documented was "Pulling at medical devises. Personal Injury Potential".

The 2/4/14 nurse note documented MR # 10 "Meets Early Release Criteria."

During an interview with the Assistant Administrator Patient Care Services, Employee Identifier (EI) #1, on 7/17/14 at 10:50 AM, EI # 1 verified the medical record did not contain a restraint order for MR # 10.

Based on review of facility policy and procedures, observations and interviews with facility staff, it was determined the facility failed to follow the policy to ensure the staff provided safe medication administration. This affected 3 of 5 patients observed and had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: Medication Administration
Department Affected: All of Patient Care Services
No date noted on policy provided.

III. Statement of Policy:
E. The administering nurses shall ensure that the medication is properly prepared for administration.
G. Medication will be administered as soon as possible after the does is prepared and by the individual preparing the dose.

Pickens County Medical Patient Care Policies and Procedures
Medication Administration
Revision date: 9/11

C. Medication Administration
2. Medication will be administered in a safe and efficient manner. All medications are to be properly labeled.
4. All medications are to be administered in an aseptic manner. Wash hands prior to administration and avoid handling the medication.
5. When using a medication cart, the cart must be secured at all times.
11. As needed (PRN) Medications should be given under the circumstances and according to the time range ordered.

Facility policy:
Home Medications
Revised date: 3/6

III. Procedure:
A. Drugs Brought into the Hospital by Patients:
5. In the event no family or significant other is present home medications are to be maintained in a secure area. The patient's room is not a secure area.
C. Use of the Patients Own Supply of Medications:
4. The patient's home supply of medication will be sorted in the patient's medication bin and administered by the nursing personnel.

During an observation of a medication pass on 7/16/2014 at 7:50 AM Employee Identifier (EI) # 13, Registered Nurse (RN) had a physician's order to give the patient's home medication Crestor 10 milligrams (mg) by mouth. This home medication was stored in the patient's bed side table, not locked in medication room as policy indicates.

The survyor observed EI # 14, RN on 7/16/14 at 11:10 AM placing a syringe of clear liquid into the drawer of an unlocked Point of Care Workstation, (COW). The surveyor questioned he/she about the syringe, EI # 14 stated, "That is his Dilaudid, it's not time for him to get it yet." This medication was not labeled with patient's name and the COW was left unattended and unlocked for approximately 15 minutes. The RN administered the narcotic medication at 11:25 AM intravenously via accessed mediport in right upper chest.

An interview was conducted on 7/17/14 at 8:15 AM with EI # 2, Director of Patient Care Services, and the aforementioned items were confirmed. The nursing staff did not follow the facilities policy.

Based on observations and interview with facility staff, it was determined the facility failed to ensure all medications in the Pharmacy, Medical Surgical Unit, and Emergency Room were not expired and were labeled upon opening with the date opened. This had the potential to affect all patients served by the facility.


Findings include:


Policy: Patient Care Procedures
Named: Multiple Dose Vial Medications
Department Affected: All of Patient Care Areas

III. Statement of policy:
B. When opened, a multiple dose vial shall be dated.
C. Once monthly, the Pharmacist will make rounds on all units using multiple dose vials, and discard all open vials to assure that no vials is left open for longer than one month. The nurse, though, must check the date on the vial before using as an added safeguard.


During the observation of a medication pass on 7/15/14 at 1:40 PM the Accudose machine on the medical surgical floor had the following open medications not labeled with date open or expired medications.

Open medications and not labeled with date open:

Humulin R Insulin 10 milliliter (ml) vial
Humulin 70/30 Insulin 10 ml vial.
Dextrose 5% 1000 ml bag.

Iron Sucrose 200 mg mixed with Normal Saline 50 ml bag expired 4/14/14.

An interview was conducted on 7/17/14 at 8:15 AM with EI # 2 and aforementioned items were confirmed.



26187

A tour of the Emergency Room (ER) was conducted on 7/15/14 at 10:55 AM with Employee Identifier (EI) # 2, Director of Patient Care Services. The triage room contained a 500 cc (cubic centimeter) bottle of Normal Saline (NS) opened with no documentation of when it was opened. A large tube of lubricating jell was opened on the counter with no documentation of when it was opened.

The trauma room contained 1- 1000 cc bottle of NS and 1 large tube of lubricating jell, both were opened with no documentation of a date.

An interview conducted 7/15/14 at 11:20 AM with EI # 2, verified the above items should have contained a lable of when they were opened.



32947

A tour of the Pharmacy was conducted on 7/15/14 at 12:45 PM. During the tour the following outdated medications were found:

Ante Room:
1. Tuberculin Purified Protein 5 (Tuberculin Unit) TU/0.1 ml (milleliter) (1 ml -10 test) - , 1 opened 12/28/13 and exp. date was 5/14.

2. Add Vantage Units /0.9 % Sodium Chloride (Na Chl) 50 milliter (ml) bags of intravenous (IV) solution, 5 bags expired (exp.) 3/1/14

3. 0.9 Na Chl 100 ml, 3 bags of IV solution exp. 12/13

4. 0.9 Na Chl 100 ml, 2 bags of IV solution exp. 10/13

Pre-Mixed Medications:

1. Fluconazole 100 milligram (mg) in 50 ml Na Chl bag of IV solution, 2 bags exp. 5/11/14

Medication Room:

2. Pharmacy (Rx) Choice Thera-plus Adult Multivitamin Liquid 4 fluid ounce ( fl oz) 118 ml x2 expiresd 1/14

3. Stomach Relief / Bismuth Subsalicylate 525 mg (237 ml) bottle x 1 exp 6/14
4. Atropine Sulfate injection (0.1 mg/ ml) 1 mg per 10 ml IV Pre-filled Syringes x 2 expired 6/14

During an interview conducted on 8/30/11 at 3:00 PM with Employee Identifier (EI) # 4, the Pharmacist, confirmed the above medications had expired.

Based on United States Health Public Food Code 2009 regulations, 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 this facility.

Findings include:

United States Health Public Food Code 2009

3-501.17 Ready-to-Eat, Potentially Hazardous Food
(Time/Temperature Control for Safety Food),
Date Marking.
...commercially processed food open and hold cold
(B) Except as specified in (D) - (F) of this section, refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety...

(C) A refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) ingredient or a portion of a refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is subsequently combined with additional ingredients or portions of food shall retain the date marking of the earliest- prepared or first prepared ingredient.

(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include:...
(2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section;
(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section...


During a tour of the Dietary Department on 7/15/14 at 10:50 AM with the Employee Identifier (EI) # 9, Registered Dietitian/Director of Dietary the surveyor observed opened food containers with no dates, food items that were inappropriately labeled, expired food items, and inappropriately stored food items.

Located in the cooler in the kitchen area were the following inappropriately stored food items which were opened with no date:

A small skillet containing 2 slices of buttered bread with 2 slices of cheese inside, with clear plastic wrap loosely covering with no date. (Identified by staff as uncooked grilled cheese sandwich).

Open package of sliced ham with clear plastic wrap labeled with 7/18/14.
Open package of sliced turkey breast labeled 7/30/14.
Small plastic container of cheese slices labeled with 7/21/14.
Square metal container with metal lid containing yellow sauce labeled with 7/22/14. This yellow sauce was identified to be cheese sauce.

Located in the walk in cooler # 1 were the following open items in plastic containers labeled with only 7/18/14. These food items were identified by EI # 9 to be as follows:
Broccoli and cheese sauce.
Spaghetti sauce.
Cream of chicken soup.
Peas.
Marinara sauce.
Buttered Carrots


Tray of cooked bacon covered with aluminum foil labeled with no date.

Located in the walk in cooler # 2 were the following open food items inappropriately stored food items only labeled with the following dates:

Large bag of uncooked dinner rolls 7/31/14.
Cheese slices with clear plastic wrap 8/15/14.
Large bag of uncooked garlic bread 7/20/14.
16 ounce (oz) bag of parmesan cheese 7/25/14.
Plastic container of black olives 7/25/14.

Located in the ice cream freezer were the following opened and inappropriately stored food items with labeled with no date.

5 pound (lb) bag of uncooked french fried potatoes.
Sliced turkey meat with plastic wrap.
4 uncooked chicken breasts.
Large bag of uncooked breaded okra.

Located in the walk in freezer were the following food items that were opened and were expired or inappropriately labeled.

5 lb bag of Mixed Vegetables with expiration date of 4/30/14.
Opened 5 lb bag of uncooked hush puppies with no open date.
2 uncooked chicken breast in plastic bag labeled with 8/31/14.

Located in the kitchen were following open items that were expired, inappropriately labeled, or no date open identified.

5 lb bag of brown sugar expired 4/26/14.
40 oz box of Redi Shred potatoes labeled 9/30.

Open with no date opened:
9- 16 oz containers of dry seasonings.
5 lb bag of pancake mix.
16 oz box of corn starch.
5 lb bag of corn meal.
40 oz bag of potato flakes.

The above mentioned items were verified at the time of Dietary Department tour with EI # 9 on 7/15/14 at 10:50 AM.

An interview conducted on 7/16/14 at 2:05 PM with EI # 9 verified the staff failed to follow policy the facilities policy for labeling open containers and inappropriately storing food items.

Based on observations and interviews, the hospital failed to maintain a clean environment in the Geri Psych Unit. This had the potential to affect all patients on the Geriatric Psychiatric (Geri Psych) Unit.

The findings include:

During the initial tour of the Geriatric (Geri) Psychatric (Psych) Unit on 7/15/14 at 11:00 AM with Employee Identifier (EI) # 7, Geri Psych Director, the floors were dull and had multiple areas where dirt was built up. The corners and room thresholds had the most accumulation of dirt buildup.

During an interview on 7/17/14 at 8:39 AM with EI # 8, the Assistant Director of Housekeeping, verified the activity room had been stripped and waxed the first week in July but the rest of the unit had not been stripped and waxed. EI # 8 stated the housekeeping staff could not complete the strip and wax of the unit with the type of patients on the Geri Psych Unit.

Based on observation and interview with facility staff, it was determined the facility failed to ensure :

1. Laboratory supplies for patient use were not expired.

2. Crash Carts were in adequate working condition in case of an emergency.

This had the potential to affect all patients.

Findings include:

A tour of the Laboratory was conducted on 07/15/14 at 11:00 AM. The following items were expired:

1. Pink Top Blood Draw (BD) Vacutainer K2 EDTA 5.4 milligrams (mg) (tube used for routine Immunohematology testing and blood donor screening) times (x) 60 expiration (exp) 6/14

2. Gray top BD Vacutainer Sodium Floride Potassium Oxalate 10 mg/8 mg x 2 exp 3/14

3. Green top BD Vacutainer Lithium Heparin 75 USP (United States Pharmacopeia) units x 1 exp 3/14

4. Red top BD Vacutainer Serum Separation Tubes (SST) 8.5 milliters (ml) x 1 exp 3/14

5. Gray top BD Vacutainer Sodium Floride Potassium Oxalate 10 mg/ 8 mg x 1 exp 3/14

An interview conducted on 7/15/14 at 11:45 AM, with Employee Identifier (EI) # 5, the Medical Technician/ Lab Manager confirmed the above findings.




34107

A tour of the medical-surgical unit was conducted on 7/15/14 at 12:00 PM. The surveyor requested to check crash contents. EI # 12, RN was unable to open the crash cart and after several attempts another nurse was summonsed to open the cart. The following items found on the cart were expired: Central line insertion tray/kit expired 5/14 and Intravenous (IV) Start kit expired 5/14.

An observation was made of the glucometer control log 7/16/14 at 11:30 AM. This revealed documentation the control solution used to check the glucometer controls for the month of July had expired as of 5/14 and 6/14. EI # 13, RN replaced the control solution at that time.

An interview was conducted with EI # 2, Director of Patient Care Services who verified the aforementioned findings.


A tour of Outpatient rehab department was conducted on 7/15/14 at 2:20 PM with EI # 11, Licensed Physical Therapy Assistant, revealed the following medical supplies were found in the store room that had expired:

4 -Wound Vac Simplace wound dressing kits expired 10/13.
2- Wound Vac drainage containers expired 6/10.
1- Wound Vac drainage container expired 6/12.
32 ounce (oz) container of Biofreeze ointment expired 1/14.
7- Tegaderm dressings expired 6/12.

Further observation revealed the following items were not labeled with date opened:

2-Decadron 30 milliliter (ml) vials open.
2-400 gram jars of Silvadene cream.
4 oz bottle of hydrogen peroxide.
Bactroban ointment.

An interview was conducted on 7/17/14 at 9:20 AM with EI # 10, Director of Rehab Services who verified the above mentioned items.

Based on observations, CDC (Center for Disease Control) guidelines for hand hygiene in health care settings, interviews with facility staff and review of hospital policies and procedures, it was determined the facility staff failed to:

1. Maintain and clean equipment to prevent potential infection to patients and staff.

2. Perform hand hygiene after removing soiled gloves and reapplying clean gloves.

3. Observe isolation guidlines for contact isolation.

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


Findings include:

Isolation Precautions
Policy # IC 106
Approved 8/12

Policy:

A. It is the policy of the Pickens County Medical Center to isolate patients diagnosed with or being evaluated for communicable diseases or epidemiologically significant organisms (e.g., MRSA, VRE Clostridium difficile, influenza, TB , etc.). Isolation precautions for patients with specific diseases and organisms are used in addition to Standard Precautions. All patients require standard precautions, but some patients may may also have an additional category of isolation precautions dependent upon transmission of the organism.

B. The Physician or Registered Nurse may initiate precautions based on known or suspected diseases as evidenced by culture results, patient condition or diagnosis.

C. The primary responsibility for initiating precautions remains with the physician.

D. It is the responsibility of the Infection Prevention and Control Department to discontinue isolation status as appropriate.

Definitions:

Standard Precautions:

Standard Precautions require that blood, all body fluids, secretions and excretions, mucous membranes and non-intact skin of all patients be treated as potentially infectious.

Contact Precautions (Orange Sign)

Contact Precautions are used for patients who are suspected or known to be infected or colonized with organisms that can be transmitted by direct contact with the patient or indirect contact with environmental surfaces or patient-care items in the patient's environment.

PPE Requirements:

Employee: Gloves and gown when contact with patient or patient's environment is expected.

Policy: # IC 109
Hand Hygiene
Revised date 5/12

I. Purpose: To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs and infections.
II. Statement of policy:

1. Hands should be decontaminated either by handwashing or use of ABHR (Alcohol Based Hand Rub) before and after any direct patient contact.

3. If hands are not visibly soiled, use an ABHR for routinely decontaminating hands in the following situations:
-Before direct contact with patients.
-After contact with inanimate objects in the immediate vicinity of the patient.
-When moving from a contaminated body site to a clean body site during patient care.
-After removing gloves.


1. During the observation of a medication pass on 7/16/14 at 8:00 A.M. the Employee Identifier (EI) # 6, Registered Nurse, was called to room 204 A
(Isolation room) to check the patient's right foot that was bleeding.
The patient was on isolation due to having a Diagnosis of Cellulitis with Methicillin-resistant Staphylococcus aureus (MRSA). The Isolation cart was outside the room door and the contact precautions was posted on the door of room. The nurse put on gown, entered the room and without performing hand hygiene put on the clean gloves. EI # 6 took the patient's leg and placed it on a clean towel, looked at the right foot to see if toe was bleeding, then placed a dry 4x4 over the patient's toe. EI # 6 then reached for paper towels and cleaned the blood spill off the floor and disposed of it in the trash bin. EI # 6 never changed soiled gloves. He/she then proceeded to clean the patient's toe on the right foot with the same soiled gloves. When EI # 6 completed the wound care, he/she removed the soiled gloves and used hand sanitizer prior to leaving the room. EI # 6 never used soap and water after wound care was provided or after cleaning the blood spill on floor. After leaving the room, EI # 6 proceeded with the medication pass. EI # 6 did not contact housekeeping about the blood spill.

An interview was conducted on 7/17/14 at 8:45 A.M. with EI # 2, Director of Patient Care Services who confirmed, the patient was in the Isolation Room with MRSA. EI # 2 confirmed that Infection control practices had not been followed by staff per agency policies.





34107


During observation of a medication pass on 7/15/14 at 12:35 PM it was noted Employee Identifier (EI) # 14, Registered Nurse, did not perform hand hygiene before preparing Demerol 25 milligrams (mg) or Phenergan 25 mg for intramuscular injection. No hand hygiene was performed prior to entering the patient's room before donning gloves or administering the injection to the patient.

An observation was made on 7/16/14 at 11:00 AM of EI # 14 performing a fingerstick blood glucose. EI # 14 failed to perform hand hygiene upon entering the room, donning gloves or before performing the procedure. EI # 14 removed gloves and used hand gel without cleaning the glucometer. EI # 14 then returned the glucometer to the nursing station and placed the unclean glucometer in the case. EI # 14 proceeded to obtain a syringe of medication from the unlocked drawer of Point of Care Workstation (COW) with no hand hygiene and proceeded to administer Dilaudid 0.5 mg intravenously through an accessed mediport.

An interview was conducted on 7/17/14 at 8:15 AM with EI # 2, Director of Patient Care Services who verified the facility policy for infection control practices was not followed by the Registered Nurse.

Based on review of the medical record and interview it was determined that physical therapy outpatient services did not notify the Physican of a frequency change from the original therapy plan of care. This affected 1 of 1 physical therapy outpatient record reviewed and had the potential to negatively affect all patients being served by this facility.

Findings include:

The facility currently has no policy regarding physician notification of changes in the plan of care.

Medical Record (MR) # 11 was admitted for physical therapy outpatient services on 6/23/14 with a diagnosis of Joint Pain Left Leg. The physician's ordered frequency was for 3 times a week for 4 weeks.
The patient was only seen 2 times the week of 6/23/14. The physician was provided a statement dated 7/1/14 by staff the patient had not missed any therapy visits by no show or cancellations.

An interview was conducted on 7/17/14 at 9:20 AM with EI # 10, Director of Rehabilitation Services and the above findings were verified.