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 a review of personnel records and interview with Employee Identifier (EI) #2, the Administrative Assistant, it was determined the hospital failed to obtain documentation of Hepatitis B screening in 10 of 15 personnel records reviewed. This had the potential to effect all patient's served.

OSHA
1910.1030(f)(2)
Hepatitis B Vaccination

1910.1030(f)(2)(i)
Hepatitis B vaccination shall be made available after the employee has received the training required in paragraph (g)(2)(vii)(I) and within 10 working days of the initial assignment to all employees who have occupational exposure unless the employee has previously received the complete hepatitis B vaccination series, antibody testing has revealed that the employee is immune, or the vaccine is contraindicated for medical reasons.

Findings include:

In 10 of 15 employee personnel records reviewed the hospital failed to include documentation of Hepatitis B injections being offered to the employees, or documentation of immunity of Hepatitis B from previous injections.

An interview conducted on 1/20/11 at 12:30 PM with EI # 2 confirmed the above findings.

Based on review of personnel files and staff interview, it was determined the hospital failed to assure required personnel had current Cardiopulmonary Resuscitation (CPR) in 9 of 13 files reviewed. This had the potential to affect all patients.

Findings include:

A review of employee personnel files on 1/20/11 revealed no documentation of CPR for 9 of 13 files reviewed.

During an interview on 1/20/11 at 12:30 PM, Employee Identifier (EI) # 1, the Chief Clinical Officer, confirmed the personnel files did not have documentation of CPR for the aforementioned employees. EI # 1 stated that she did not know which clinical staff had current CPR.

Based on review of departmental policies and procedures and interview with staff, the facility failed to follow their policy for review of departmental manuals. This had the potential to affect all patients.

Findings include:

The policy titled "Policy and Procedure Review" included, "...Policy and procedures should be reviewed annually".

During the survey departmental manuals to include Dietary, Nursing, Emergency Room, Radiology, Laboratory and Pharmacy were reviewed.

There was no documentation of an annual review and none could be provided.

An interview with Employee Identifier # 1, the Chief Clinical Officer, on 1/20/11 at 9:10 AM confirmed no policy review signature sheets were available for review.

Based on review of policies, observation of the crash carts and review of the facilities emergency crash cart checklist (24 hour shift checklist), it was determined the facility failed to:
1. Assure safe operation and readiness of the facilities defibrillator's.
2. Assure integrity of the emergency crash carts.

This affected 3 of 3 emergency crash carts in the facility.

Policy
Title: Crash Cart
Effective Date: July 1, 1993

Statement of Purpose
To assure readiness and uniformity of all crash carts for utilization in an emergency/code situation on all patient areas.

All crash carts will be checked by nursing personnel every 12 hours. "Break Away" locks are placed on the drug and RT (respiratory therapy) drawers. When the lock is broken, the cart must be checked and all of the contents verified for completeness. Integrity of the cart cannot be broken except in an emergency/code situation.

Procedure
Nursing Responsibilities
2. Verifying each shift: defibrillator reaches 200 watt-second (joules)... Sign the crash cart check sheet, post review of cart.

Pharmacy Nurse Responsibilities
1. Daily check for integrity of "Break-Away" lock.
6. "Sign the crash cart check sheet, post review of cart".


1. During a tour of the Emergency Room (ER) on 1/18/11 at 1:25 PM and on 1/19/11 at 9:30 AM with Employee Identifier (EI) # 3, the Quality Assurance (QA) Nurse, the surveyor observed that the crash cart in the ER trauma room and the crash cart in ER #2 (room 145), did not have "Break-Away" locks on the drawers.

A review of the 24 hour shift check list on 1/19/11 at 9:30 AM for 1/1/11 to 1/17/11 revealed the following:

Trauma Room Crash Cart and ER #2 Crash Cart:
A. Defibrillator checks and signing that the "Break-Away" locks were on drawers were not documented on either shift (7a-7p and 7p-7a) on 1/5/11, 1/7/11, 1/8/11,/1/9/11,1/10/11,1/13/11 and 1/17/11.
B. Defibrillator checks and signing that the "Break-Away" locks were on drawers were not documented on 7a-7p shift on 1/11/11.
C. Defibrillator checks and signing that the "Break-Away" locks were on drawers were not documented on 7p-7a shift on 1/1/11, 1/2/11,/1/3/11,/1/4/11,1/6/11, 1/12/11, 1/14/11, 1/15/11 and 1/16/11.




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2. A tour of the Radiology Department was conducted 1/18/11 at 1:00 PM with EI #10, Director of Radiology.
Observation by the surveyor revealed an emergency cart in the
CAT (Computerized Axial Tomography) Scan room. There was no documentation the cart was checked for correct function of the defibrillator or if the "Break-Away" locks were intact and on drawers. EI # 10 stated the cart was checked once a week but no record could be provided.

An interview conducted 1/19/11 at 9:30 AM with EI # 3, the QA Nurse, confirmed the above findings.

Based on acceptable standards of practice, medical record review, facility policy review and interview with staff, it was determined the facility failed to assess 3 of 3 patients with wounds and failed to ensure facility policy was followed for 1 of 2 patients receiving blood transfusions. This affected medical records (MR) # 12, # 8, # 10 and # 7.

Findings Include:

Code of Alabama 1975
Nurse Practice Act
34-21-1. Definitions.

a. Practice of Professional Nursing. "The performance, for compensation, of any act in the care and counseling of persons or in the promotion and maintenance of health and prevention of illness and injury based upon the nursing process which includes systematic data gathering, assessment, appropriate nursing judgment and evaluation of human responses to actual or potential health problems..."

Facility Policy:

Standard Policy and Procedure for Blood Administration
9. Two nurses, one being and (an) RN (registered nurse) must check the blood and sign the compatibility lab slip.


1. Medical Record (MR) #12 was admitted to the hospital on 3/17/10 with diagnosis of Congestive Heart Failure.

Review of the medical record revealed documentation by the Skilled Nurse (SN) on 3/17/10 of the initial nursing assessment as follows:
Skin Assessment: Please indicate all body marks, rashes, decubitus, scars, amputations, ostomy sites, other markings and indicate cm (centimeter) size. There were no wounds indicated.

Further review of the medical record revealed documentation by the Skilled Nurse (SN) on 3/17/10 as follows: 1800 admitted to room... 2000 RN shift assessment completed... Pt (patient) with Stage III decubitius ulcer to L (left) heel. Dsg (dressing) applied - area cleaned with NS (Normal Saline) - pat dry and telfa with 4 x 4 applied - covered with kling - secured with paper tape. There was no docmentation of the wound size.

An interview on 1/20/11 at 10:14 AM with Employee Identifier (EI) #1, the Chief Clinical Officer, confirmed there was no documentation of a Stage 3 wound on the initial nursing assessment.




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2. MR # 8 was admitted to the hospital on 6/6/10 with diagnosis of Cellulitis to the foot due to MRSA (Methicillin-resistant Staphylococcus aureus).
The patient was discharged on 6/18/10.

Review of the History and Physical on admission to the hospital revealed documentation by the physician on 6/6/10, "....ulceration on the medical aspect of the base of left big toe, approximately 3/4 of an inch in size, with unhealthy looking granulation tissue at the base, slightly purulent drainage seen...."

Review of the physician progress notes revealed the physician debrided the wound on 6/9/10 and 6/14/10.

Review of the skilled nursing notes revealed documentation by the SN on 6/6/10 of the initial nursing assessment as follows: "Skin Assessment: Please indicate all body marks, rashes, decubitus, scars, amputations, ostomy sites, other markings and indicate cm (centimeter) size." There were no wounds indicated.

Review of the skilled nursing notes dated 6/8/10, 6/9/10, 6/12/10, 6/13/10, 6/14/10, 6/15/10, and 6/18/10 revealed documentation that the area on the left foot was a decubitus. There was no documentation regarding the size of the area. The only description of the area was on 6/12/10 and 6/13/10. The area was documented as being pink and yellow in color. On 6/17/10 and on an undated note documented the area was pink in color. There was no documentation regarding the size or appearance of the area after the physician debrided the area on 6/9/10 and 6/14/10.

An interview on 1/20/11 at 9:10 AM with EI #1 confirmed there was no skin assessment documented on admission and it was not consistently documented during the twelve days the patient was in the hospital. EI # 1 confirmed the nursing notes contained the wrong terminology as the patient was admitted with an ulcerated area and not a decubitus ulcer. EI # 1 stated the physician had confirmed it was an ulcer and not a decubitus.

During this interview the surveyor asked EI # 1 when should wounds be measured and he/she stated, "Should do on admission and if any changes occur." EI # 1 confirmed the wound was not measured after the wound was debrided on 6/9/10 and 6/14/10 but should have been measured.

3. MR # 10 was admitted to the hospital on 11/2/10 with diagnoses including Change in Mental Status, Anemia Related to rectal bleeding and Rectal Bleeding.

Review of the medical record revealed an order for two units of PRBC (packed red blood cells) on 11/5/10.

Review of the laboratory (lab) slip for the PRBCs administered at 8:05 AM on 11/5/10 revealed the lab compatibility slip was not signed by one RN Registered Nurse) and another nurse as required by hospital policy.

Review of the hospital Blood/Blood Component Transfusion Flow Sheet revealed a student nurse was the only person who signed to verify the transfusion component. The form indicated the verification should have been done by two nurses (one RN and another RN or LPN [Licensed Practical Nurse]).

During interview on 1/20/11 at 9:20 AM, EI # 1 confirmed the above findings.


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4. MR #7 was admitted to the hospital on 4/14/10 with Anemia and Decubitus Ulcer Stage IV to buttocks.

Review of the MR revealed documentation by the Skilled Nurse (SN) on 4/14/10 of the initial nursing assessment as follows:
Skin Assessment: Please indicate all body marks, rashes, decubitus, scars, amputations, ostomy sites, other markings and indicate cm size. Review of the initial assessment revealed the nurse documented the patient had a Decubitus Stage IV to coccyx which was tunneling and a decubitus to the left heal. There was no measurements included in the assessment.

Further review revealed the Physician debrided the wound to the coccyx on 4/17/10 and 4/19/10. There was no documentation to include the size of the wound.

An interview conducted 1/20/11 at 9:40 AM with EI #1 confirmed the SN failed to document a complete skin assessment on admission, upon change in the wound and consecutively throughout the patients hospital stay (4/14/10-4/22/10). The EI #1 was asked by the surveyor when and how often wounds should be measured. The reply was "Should do on admission and when any change occurs."

Based on observations, interviews, review of job descriptions for Licensed Practical Nurses (LPN) and review of personnel records, it was determined the hospital failed to assure the competency skills of 4 of 5 of the nursing staff had been assessed and failed to ensure 1 of 1 LPN's administering Intravenous (IV) medications was IV certified. This had the potential to affect all patients.

Findings include:

Job Description for L. P. N.

III. Brief Summary of Job Duties:

Paragraph 7

Initiation, administering, and recording of I.V. therapy following the I.V. therapy policy after completion, of an I.V. course. Performance of I.V. therapy only within job scope (Not I.V. push, Blood transfusion, Hyper alimentation, etcetera).

1. Review of the personnel files revealed no competencies had been documented for 4 of 5 nursing staff reviewed.

During an interview on 1/20/11 at 12:30 PM, Employee Identifier (EI) # 1, the Chief Clinical Officer, was unable to provide documentation of competencies for 4 of the 5 nursing staff reviewed.

2. On 1/19/11 at 9:05 AM the surveyor observed EI # 11, the LPN, prepare medications for medical record (MR) # 4. At 9:20 AM, EI # 11 prepared Rocephin 1 Gram to be administered IV piggyback. The IV site was infiltrated and EI # 11 was unable to administer the Rocephin.

Review of EI # 11's personnel record revealed there was no documentation he/she was IV certified or had completed and IV course as required per hospital policy.

During an interview on 1/20/11 at 11:00 AM, EI # 1 was unable to provide documentation that EI # 11 was IV certified or had completed an IV course. EI #1 stated IV's and IV administration (piggyback only) was within the LPN's Scope of Practice. This statement did not correlate with the hospital policy.

Based on Medical Record (MR) reviews and interviews with the facility staff, it was determined the MR did not include information necessary to monitor the patient's condition in 2 of 2 patients (MR # 7 and # 3) requiring sliding scale insulin, 1 of 1 patient (MR # 9) requiring accuchecks and 2 of 3 patients (MR #12 and #8) with a wound. This had the potential to affect all patients served.

Findings Include:

1. MR #12 was admitted to the hospital on 3/17/10 with Congestive Heart Failure.

Review of the MR revealed documentation by the Skilled Nurse (SN) on 3/17/11 as follows: 1800 admitted to room... 2000 RN shift assessment completed... Pt (patient) with Stage III decubitus ulcer to L (left) heel. Dsg (dressing) applied - area cleaned with NS (Normal Saline) - pat dry and telfa with 4 x 4 applied - covered with kling - secured with paper tape.

There was no physician order for the wound care provided.

An interview on 1/20/11 at 10:14 AM with Employee Identifier (EI) #1, the Chief Clinical Officer, confirmed there were no wound care orders in the MR.


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2. MR # 8 was admitted to the hospital on 6/6/10 with a diagnosis of Cellulitis of the foot with MRSA (Methicillin-resistant Staphylococcus aureus). The patient was discharged from the hospital on 6/18/10.

Review of the medical record revealed no Physician orders for wound care.

Review of the skilled nursing notes revealed wound documentation: 6/6/10 "Dressing dry on left foot" and 6/7/10 "Dressing intact to left foot"; 6/12/10 "Decubitis to left foot cleaned with peroxide, flushed with NS (normal saline)...." There was no documentation who applied the dressing and there was no order for the dressing for 6/6/10 and 6/7/10. There was no order for the wound to be cleaned with peroxide and flushed with NS as was performed on 6/12/10.

During an interview on 1/20/11 at 9:10 AM, EI # 1, Chief Clinical Officer, confirmed there was no order for the dressing or the wound care and should not have been done without an order. During and interview on 1/19/11 at 2:00 PM EI #1 stated, "The physician writes orders for how he wants wound care to be done."



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3. MR #7 was admitted to the hospital on 4/14/10 with Anemia and Decubitus Ulcer Stage 4 to buttocks.

Review of the MR revealed Physician Orders dated 4/14/10 to check blood sugars AC (before meals) and HS (at bedtime) and to use sliding scale insulin. There was no specific sliding scale ordered to direct staff on the amount of insulin that was to be given.

An interview with EI # 1, 1/20/11 at 9:40 AM confirmed there was no sliding scale specifics in the MR.


4. MR #3 was admitted to the hospital on 8/11/10 with Uncontrolled Diabetes Mellitus and Dehydration.

Review of the MR revealed Physician Orders dated 8/11/10 to check blood sugars AC (before meals) and HS (at bedtime) and to use sliding scale insulin. There was no specific sliding scale ordered to direct staff on the amount of insulin that was to be given.
.

An interview with the EI # 1, 1/20/11 at 11:30 AM confirmed there was no sliding scale specifics in the MR to direct staff on the amount of insulin that was to be given.
.

5. MR # 9 was admitted to the facility 11/26/10 with Anemia related to blood loss.

Review of the MR revealed CBG's (Capillary Blood Glucose) was documented 4 times a day by the SN. There was no physician's order found in the MR to obtain the CBG's.

An interview conducted 1/20/11 at 12:30 PM with EI#1 confirmed there was no order written to obtain the CBG's.

Based on policy review and interview with Employee Identifier (EI) # 12, the Director of Labaratory, it was determined the facility failed to ensure a system was in place to take appropriate action when notified that blood or blood components it received are at increased risk of transmitting Human Immunodeficiency virus (HIV) or Hepatitis C Virus (HCV). This had the potential to negatively affect all patients receiving blood or blood products.

Review of the policy and procedure book revealed there was no policy or procedure available for identifying the correct procedure of dealing with Infectious Blood and Blood Products.

An interview conducted 1/18/11 at 1:45 PM with EI #12 confirmed there was no policy.

Based on observations, interviews and review of facility policies, it was determined the hospital failed to ensure food was stored in a safe and sanitary manner and sanitary measures were used in the cleaning and sanitation of cooking and serving utensils. This had the potential to negatively affect all patients.

Findings include:

Facility Policy

Dish Machine Operation

2. Add detergent (1 cup to the wash water) and fill the jet dry dispenser.

(There was no date as to when the dietary policies had last been reviewed.)

1. Observation on 1/19/11 at 8:30 AM of the refrigerator in the food service area revealed the following: 7 styrofoam cups dated 1/18/11 were not labeled with the contents of the cups; 1 bowl covered with tin foil was not labeled or dated; a paper plate covered with clear wrap containing 1/2 of an onion was unlabeled and undated; 1/2 of a bell pepper covered with clear wrap was undated and unlabeled; a paper plate covered with clear wrap containing 2 slices of cheese was undated and unlabeled.

During an interview on 1/19/11 at 8:40 AM, Employee Identifier (EI) # 5, the Dietary Manager, stated jello was in the styrofoam cups but did not know what was in the bowl covered with tin foil. EI # 5 confirmed the aforementioned containers were undated and unlabeled. EI # 5 confirmed the items should have been dated and labeled.

2. During a tour of the food service area on 1/18/11 at 12:05 PM, the surveyor observed 2 pans filled with water sitting in the first compartment of the three compartment sink. There was no water in any of the compartments of the three compartment sink.

During an interview on 1/18/11 at 1:40 PM, EI # 6, the dietary cook, stated that the 3 compartment sink,"....hadn't been used in some time...." EI # 6 stated that after they wash and rinse the pots and pans they put them in the dishwasher. EI # 6 stated that if the 3 compartment sink was in use, he/she did not know how much sanitizer to use or how to check to be sure the correct amount of sanitizer was used or what the temperature of the water should be.

During an interview on 1/18/11 at 2:00 PM, EI # 5 stated there were no instructions or policy for the use of the 3 compartment sink.

3. On 1/18/11 at 1:45 PM the surveyor observed EI # 6 washing the dishes in the dishwasher. EI # 6 stated he/she put about 1/4 cup of the Rejoice detergent in the dishwasher to wash the dishes.

During a tour of the food service area on 1/19/11 at 8:10 AM, the surveyor observed a 50 pound box of Rejoice ( a fine manual spray dried powder pot and pan detergent) in the dishwasher room. Handwritten on the top of the Rejoice box was "Not for Dishwasher".

The Rejoice had the following directions: "(Read and understand label and Material Safety Data Sheet (MSDS). Use dilution: 1 ounce to 3 gallons of water. DO NOT MIX WITH ANYTHING BUT WATER. 1. Pre-flush ware to be cleaned. Lukewarm water works best. 2. Wash in a solution of 1 ounce water 110 degrees F (Fahrenheit) (tank 1). 3. Rinse with clear water-tank 2. 4. Sanitize with a recommended sanitizer (tank 3). 5. Air dry - never towel dry." There was no documentation the Rejoice was to be used in the dishwasher.

At the time of this observation the surveyor questioned EI # 5 about the Rejoice being used in the dishwasher. EI # 5 stated the salesman who brought the Rejoice had said it could be used for the dishwasher but the hospital maintenance personnel had written "Not for Dishwasher" on top of the Rejoice box.

Based on interviews with the staff and review of the directions for use on the Cavicide container, it was determined the facility failed to ensure the central sterile staff followed the directions for correct mixing of the Cavicide to pre-clean the suture sets prior to sterilization. This had the potential to affect all patients.


Findings include:

1. Directions for use on the Cavicide Container:

"For use as a manual pre-cleanser: Thoroughly rinse instruments under running water to remove visible gross debris. Place instruments in container with 1 ounce Cavicide per liter of water. Scrub instruments while submerged for 30 seconds with a stiff brush. Remove and rinse instruments. Follow with appropriate cleaning and disinfection process. Discard solution after use."

2. A tour of the Central Sterile area was conducted on 1/19/11 at 9:40 AM with Employee Identifier (EI) # 8, the certified nursing assistant (CNA) who assisted in the Central Sterile area. EI # 8 stated about the only thing they sterilize were the suture sets used in the emergency department (ED) since they no longer do surgeries.

While describing how the suture sets are pre-cleaned, EI # 8 stated that he/she put about 1/2 cup of Cavicide into 3-4 cups of warm water to pre-clean the suture sets. Then EI # 8 stated that he/she "just sort of guessed" as to how much to use. EI # 8 confirmed he/she did not know the correct amount of Cavicide or water to be used to pre-clean the suture sets.

3. At 9:55 AM on 1/19/11 the surveyor was joined by EI # 7, the Licensed Practical Nurse (LPN) over Central Sterile.

The surveyor questioned EI # 7 regarding how he/she mixed the Cavicide to pre-clean the suture sets. EI #7 stated that 1 ounce (30 cubic centimeters) of Cavicide was mixed with water in the metal pan in the sink. EI # 7 confirmed he/she did not know how much water was suppose to be used to mix with the Cavicide.

EI # 7 confirmed they were the only two employees who mixed the Cavicide.

Based on review of the Emergency Room (ER) log, review of policies and interview with facility staff, it was determined the facility failed to track the care provided to each individual who presented to the ER for an emergency medical condition. This has the potential to affect all patients receiving ER services.


Policy:
Number: 03-26-47
Title: EMTALA: Central Log
Effective Date: January, 1996

Purpose:
To track the care provided to each individual who comes to the hospital seeking care for an emergency medical condition.

Policy:
Each facility that provides emergency services will maintain a central log to include information on each individual who comes to the hospital requesting treatment,...

Procedure:
... 4. The log must contain: the name of the individual seeking assistance and the disposition (permitted dispositions include: 1) patient refused treatment, 2) was refused treatment by facility, 3) transferred, 4) admitted and treatment, 5) stabilized and transferred, or 6) discharged).

A review of the ER Central Log book from 12/12/10 to 1/17/11 conducted by the surveyor on 1/18/11 at 12:10 PM revealed 10 of 34 patient entries did not have the disposition documented.

An interview conducted on 1/20/11 at 10:20 AM with Employee Identifier #1, the Chief Clinical Officer, verified the ER log was incomplete.

Based on medical record review and staff interview, it was determined the hospital did not ensure 2 of 2 patients discharged to home health were given a list of available home health agencies to choose from. This affected medical record (MR) # 1 and # 3 and had the potential to effect all patients served.

Findings include:

1. MR # 1 was admitted to the hospital on 8/27/10 with diagnoses of Change in Mental Status and Dehydration.

Review of the MR revealed the patient was discharged home on 8/30/10 to be followed by home health. There was no documentation in the MR the patient was given a list of home health agencies to choose from.

During interview on 1/20/11 at 9:15 AM, Employee Identifier (EI) # 1, the Chief Clinical Officer, confirmed there was no documentation in the MR the patient had been given a list of home health agencies to choose from. EI # 1 confirmed the hospital had a form with the home health agencies listed but the form was not in the MR. EI # 1 stated the form was not always given to the patients for them to choose an agency.



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2. MR # 3 was admitted to the hospital on 8/11/10 with diagnoses of Uncontrolled Diabetes Mellitus and Dehydration.

Review of the MR revealed the patient was to be followed by home health upon discharge. There was no documentation in the MR the patient was given a list of home health agencies to choose from.

An interview conducted 1/20/11 at 11:30 AM with EI #1 confirmed there was no documentation in the MR the patient was given a list of home health agencies to choose from. EI #1 gave a form to the surveyor which had several Home Health Agencies listed but the form was not in the MR. EI #1 stated the form was not always given to the patients for them to choose an agency.