HospitalInspections.org

Based on review of facility records, observation and interview the facility failed to ensure:

1. The Dietary Manager had provided the training/competency required to function.

2. The Dietitian reviewed and approved the menus for each patient.

3. The employees were oriented and deemed competent in their dietary duties.

4. The nutritious needs of the patients were met according to the Recommenced Daily Allowances.

5. The Therapeutic Diet Manual was approved and available to all dietary staff.

Findings include:

Refer to A 620, A 621, A 622, A 629, and A 631 for findings.

Based on observations, interview and department rounds, the hospital failed to the ensure the staff identified and corrected environmental safety concerns on the acute patient units.

During a tour of the Geriatric Psychiatric Unit (GPU) conducted on 1/9/18 at 10:45 AM and 1/10/18 at 9:30 AM with Employee Identifier (EI) # 2, Director of GPU, the surveyor observed the following:

Unit hallway hand bars were not flushed to the wall or filled to prevent wrapping around and injury to patients.

During the tour of patients' room with EI # 2 conducted on 1/9/18 at 11:00 AM, the surveyor observed the door hinges in rooms 233, 234, 235, 236, 237, 238 and 239 were exposed and able to support body weight.

Patient's rooms 236, 237, 238 and 239 had extra chair for visitors to sit on which were non- essential furniture in the patient's room.

In an interview conducted on 1/11/18 at 2:30 PM with EI # 2 who confirmed the above mentioned findings.

Based on review of the facility's policy and procedures, medical record (MR) and interview with the staff, it was determined the staff failed to perform wound care according to the physician's order and wound management.

This affected 1 of 2 wound charts reviewed including Patient Identifier (PI) # 17, and had the potential to affect all patients served in this facility.

Findings include:

Subject: pressure Ulcer Prevention and Treatment Practice Guidelines
Revised date: 7/10/12

II. Policy:
It is the policy that Pressure Ulcer Prevention and Treatment Guidelines will be initiated for all non-surgical wounds. This includes pressure ulcers (Stage I, II, III, IV and Unable to Stage), skin tears and abrasions.

III. Procedure:

A. Risk Assessment

4. Reassessment of risk (Braden Scale) will be done by a licensed nurse (Registered Nurse or Licensed Practical Nurse) weekly and appropriate referrals ( example Dietary, Physical Therapy) will be made with any change. Reassessment date is to be documented on Kardex. MD will be notified.

F. Documentation: In Meditech System

1. Initial documentation should include the following. These should also be documented daily with each dressing changes.
a. Location
b. Size
c Stage - initially and weekly
d. Exudate
e. Necrotic Tissue
f. Odor
g. Treatment used.
h. Pain
2. Wound/ Pressure Ulcer present on admission must be documented within 24 hours along with description by the physician.
(See above F1)

Measurement length- width - depth in centimeters.

1. PI # 17 was admitted on 12/5/17 with the diagnosis of Cellulitis.

Review of the Physician Order 12/5/17 revealed wound care to right ischial decubitus as follows: Apply Saline/ Betadine wet to dry dressing, covered with 4x4 gauze and secure with paper tape every morning.

Review of the Nurse Note (NN) dated 12/5/17 and 12/6/17 documentation wound care was provided but failed to document the wound depth.

Review of the NN 12/9/17 revealed no wound measurement was performed on the right ischial decubitus.

Review of the Physician Order 12/6/17 revealed wound care as follows: clean Right hip decubitus twice daily and repack with 1/10 inch Betadine/ Saline moistened gauze, wet to dry.

Review of the NN 12/7/17 revealed no documentation the wound care was provided to the right hip.

Review of Physician Order 12/8/17 revealed wound care orders to the Left hip/ leg and Right thigh as follows: saline wet to dry dressing, covered with 4x4 gauze and secure with paper tape.

Review of the NN 12/8/17 revealed no documentation wound care was provided to the left hip and thigh or the right hip.

An interview conducted on 1/11/18 at 12:15 PM with Employee Identifier (EI) #1, Director of Quality Management ( D-QM) who confirmed the staff failed to follow facility's policy and procedures including the physician's orders.

Based on review of facility policies and procedures, observations and interviews with facility staff, it was determined the nurse failed to prepare and administer medications according to the facility's policies.

This affected 1 of 20 medical records reviewed, including Patient Identifier (PI ) # 13, and observation of medication administration for 2 unsampled patients. These deficient practices also have the potential to negatively affect all patients admitted to this facility.

Findings include:

Facility Policy:

Insulin Administration and Glycemic Control

I. Purpose:

To provide guidelines for the safe administration of insulin and promote enhanced inpatient glycemic control...

III. Policy:

... C. Two (2) licensed nursing staff must verify that the insulin type and dosage are correct and initial the MAR (Medication Administration Record) at each administration of insulin. Initials of the nurse verifying medication to be placed at the left of administration time...

V. Procedure:

C. Have second licensed nurse verify correct dose, medication and initial MAR to the left of administration time.

******

Facility Policy:

Multiple Dose Vials

"I. Purpose:

To provide guidelines to ensure that all injectable multiple dose vials are discarded 28 days after initial entry.

II. Policy:

It shall be the policy of Pickens County Medical Center that multiple dose vials will be discarded:

28 days after initial entry...

III. Procedure:

A. All multiple dose vials shall be dated and initialed upon initial entry...

C. Multiple dose vials may be retained for use for 28 days after initial entry... The vial may ONLY be used after initial entry if the initial entry date and initials are noted..."

******

1. PI # 13 was admitted to the hospital on 12/29/17 with diagnosis of Chest Pain and Pneumonia.

An observation of medication administration for PI # 13 was conducted on 1/9/16 at 11:20 AM with EI (Employee Identifier) # 13, Registered Nurse (RN). During this observation, EI # 13 removed Humulin R (Regular) 30 ml (Milliliters) insulin vial from the medication refrigerator. The surveyor observed the date and initials were smeared and unidentifiable. The surveyor asked EI # 13, "what is the date and initials documented on the insulin vial?" EI # 13 stated she could not read the date or the initials on the insulin vial. EI # 13 stated, "I will get in trouble for discarding over a half bottle of insulin, You know what I mean." EI # 13 failed to veriyfy when the multidose vial was opened per policy.

EI # 13 proceeded to draw up 8 units of insulin for PI # 13 and 6 units of insulin for an unsampled patient. EI # 13 administered the insulin to the patients and did not verify the insulin type and dosage were correct with a second licensed nursing staff member per policy.

In an interview on 1/11/18 at 6:08 PM, EI # 1, Director of Quality Management confirmed the above findings.

2. An observation of medication administration for an unsampled patient was conducted on 1/9/16 at 11:23 AM with EI # 4, RN. During this observation, EI # 4 removed Humulin R 30 ml insulin vial from the medication refrigerator. The surveyor observed the date and initials were smeared and unidentifiable. The surveyor asked EI # 4, "what is the date and initials documented on the insulin vial?" EI # 4 stated she could not read the date or the initials on the insulin vial because the writing was smeared. EI # 4 failed to verify when the multidose vial was opened per policy.

EI # 4 proceeded to draw up 2 units of insulin for the unsampled patient. EI # 4 administered the insulin to the patient and did not verify the insulin type and dosage were correct with a second licensed nursing staff member per policy.

In an interview on 1/11/18 at 6:08 PM, EI # 1, Director of Quality Management confirmed the above findings.

Based on review of the hospital's policy and procedures, observations and interviews, it was determined the facility failed to ensure all medications available for patient use were not expired. This had the potential to negatively affect all patient served by this hospital.

Findings include:

Medication Inventory and Maintenance

Purpose:
To provide a mechanism for procurement and maintenance of pharmaceuticals.

E. Outdated and/ or unusable products and defective products

Outdated/ unusable drugs will be removed from regular inventory and stored on a designated quarantined area. From there, the drug will be returned for credit using a reverse distributor or destruction by a waste vendor.

1. Identification of all outdated/ unusable drug items will be made during routine monthly inspection of the department and on nursing units by designated pharmacy personnel. When an expired dug is discovered in stock or is returned to the pharmacy, it will be placed in the appropriate box in the designated area.

******

Policy:

Crash Cart Usage And Replenishing

I. Goal:

Ensure available drugs and emergency supplies in the event of a respiratory or cardiac arrest.

II. Objective:

Define location of crash carts for general nursing.

IV. Procedure For Replenishing Crash Carts:

1. When in the hospital, the pharmacist shall replenish the cart.
2. If the Pharmacist is off duty, the designated Charge Nurse from each area shall be responsible for restocking the cart after each use...

V. Procedure For Checking Crash Carts:

Crash carts shall be checked for readiness each shift by the designated nurse in charge of each nursing area, utilizing the following procedure:

1. Replacement of supplies...
5. ...Inventory checklist for expired products and all drugs and supplies which will expire within next 30 days will be replaced..."

******

A tour of the Operating Room (OR) and Recovery Room (RR) was conducted on 1/9/18 at 2:30 PM with Employee Identifier (EI) # 5, OR Nurse Manager and EI # 6, Licensed Practical Nurse (LPN) OR/ RR.

The surveyor requested EI # 5 to open the RR Emergency Cart, the surveyor found on the top shelf an 2 expired medications, Digoxin ampoule (one)Dopamine intravenous bag (one) 500 milliliters (ml) that expired November 2017. The surveyor showed EI # 5 the expired medication in the Emergency Cart, EI # 6 stated that the Pharmacist told them to keep the expired medicine (Dopamine) due to shortage of the medication and he/ she would rather " have it on hand and not at all". The surveyor then asked EI # 5 if there had been any follow up made regarding the availability and possible substitute for the expired medication (Dopamine), EI # 5 informed the surveyor no update from the Pharmacy regarding the expired medication (Dopamine).

In an interview conducted on 1/10/18 at 3:30 PM with EI # 5 who confirmed the above mentioned findings.




37268

During a tour of the 2nd (second) floor Medical Unit on 1/9/18 at 12:03 PM with EI # 13, Registered Nurse the surveyor found the following expired medications and supplies on the crash cart:

1. Dopamine HCL 800 mg/250 ml, Expiration date 11/2017.
2. Single use Laryngeal Mask - Sterile # 5 Adult 70-100 kg (kilograms) expired 11/2017.
3. Stylet 10 FR (French) expired 8/2017.
4. 0.9 % (percent) Sodium Chloride 150 ml expired 11/1/2017 (2 bags).
5. 0.9 % (percent) Sodium Chloride 1000 ml expired 1/1/2018 (2 bags).
6. 0.9 % (percent) Sodium Chloride 100 ml expired 8/1/2017 (3 bags).

An interview was conducted on 1/9/18 at 2:00 PM with EI # 14, Pharmacist who stated he/she was aware of the expired Dopamine medication throughout the hospital and the Pharmacy Director was also aware of the expired Dopamine throughout the hospital. EI # 14 stated the Dopamine has been on back order for a while.

An interview was conducted on 1/11/18 at 6:45 PM with EI # 1 who confirmed the above findings.

During a tour of the Pharmacy Room on 1/9/18 at 1:23 PM with EI # 14, Pharmacist the surveyor found the following expired medications and supplies:

Propylthiouracil tablets 50 mg (milligrams) (100 tablets) expired 11/2016

Ziprasidone Hydrochloride Capsule 40 mg (30 capsules) expired 11/2017

Dopamine HCL (Hydrochloride) and 5 % (percent) Dextrose 800 mg per 250 ml (one 250 ml bag) expired 11/2017

An interview was conducted on 1/10/18 at 9:00 AM with EI # 15, Director Of Pharmacy who confirmed the above findings. EI # 15 stated he/she was aware of the shortage and back order for Dopamine. E I # 15 also stated he/she would rather have the expired Dopamine on hand than not have any for use if needed during an emergency. EI # 15 stated "there is a shortage everywhere". EI # 15 stated he/she does not have any documentation for addressing this issue in the Pharmacy and Therapeutics Minutes.



39080

During a tour of the facility's Emergency Room on 1/10/18 at 10:00 AM with EI # 3, Director of Emergency Room, the surveyor found the following medications and supplies to be out of date:

1. Trauma Room # 2 crash cart, top drawer:
Dopamine HCL 800 milligrams/250 milliliters, Expiration date 11/2017
2. Trauma Room # 1,# 2
Powdered gloves which were banned by the FDA in 2016.

Review of the ER Supply Checklist which for expired items, dated monthly for 2017 revealed no employee initials for the months of November and December for Trauma room #1 and #2 and no employee initial for the month of December for the small bins over the refrigerator.

An interview was conducted on 1/10/18 at 10:00 AM with EI # 3, who confirmed the above findings and stated powered gloves were supposed to have been removed from the facility over a year ago.

An interview was conducted on 1/11/18 at 12:56 PM with EI # 15, Director of Pharmacy, who stated he/she was aware of the expired medications and that it was the responsibility of the pharmacy staff to check medications in the top drawers of the crash carts.

Based on review of personnel files, facility policies and staff interviews, the facility failed to ensure the Dietary Manager had been provided the training/competency required to function in this position. This affected 1 of 1 dietary personnel files and had the potential to negatively affect all patients served by this facility.

Findings include:

Policy: Subject: New Personnel Training and Education Program
Pickens County Medical Center (PCMS)
Department: Nutritional Services
Effective Date: 03/99
Reviewed: 09/11

Purpose:

All new employees will participate in the PCMC hospital-wide orientation as well as a Nutritional services Department orientation.

Responsibilities:
1. The Director of Nutritional Services has the ultimate responsibility for ensuring each employee obtains both orientations....

Procedure:

1. The Supervisor/designee will provide the departmental orientation on the first day of work....

3. An evaluation of the orientation program will be completed by each newly oriented employee at the end of the orientation. The evaluation form will be provided to the employee after the orientation process has been completed. The information will be used to recommend changes in the orientation program.

4. All orientation evaluations will be maintained in the Education Coordinator's office.

*****
Policy: Subject: On-The-Job-Training (OJT) Program
PCMS
Department: Nutritional Services
Effective Date: 08/08
Reviewed: 09/11

Purpose: To establish an standardized procedures for conducting OJT in the Nutritional Services Department.

Policy:

1. The Director of Nutritional Services has ultimate responsibility to ensure each employee obtains appropriate OJT.

Procedure:

1. All new employee trainees are assigned to work side-by-side a competent individual who has had prior training and experience.

2. Employee trainees are again oriented to their work area in more detail with their trainer performing the function....

4. The trainer works with the trainee until competency is demonstrated.

5. Competency validation will begin upon hire and be completed within the 90 day probation period to the extent possible utilizing Demonstration, Cognitive Test, Observation and Self Study Packet.

*****
Policy: Boxed Meals
PCMC Nutritional Services
Effective Date: 12/10
Revised 9/11

Purpose: to make food available for patients after room service operating hours.

Policy: Frozen dinners will be delivered to nursing units daily by Nutritional Services personnel;...

Procedure:...

C. The dinners will be delivered to the units and placed in refrigerators by the assigned ambassador beginning at 1:00 pm; outdated frozen meals will be discared at this time....


1. Employee Identifier (EI) # 7, Dietary Manager, was hired in this new position at the PCMS on 7/27/14.

Review of the personnel file for EI # 7 was conducted with the assistance of EI # 8, Director of Human Resources, on 1/11/18 at 12:00 PM, revealed no documentation of dietary orientation, dietary competency and no job description as the Dietary Manager.

An interview was conducted on 1/11/18 at 5:40 PM with EI # 7, who confirmed the aforementioned findings.

Based on review of the facility policies, interviews with staff and weekly diet report for the months of November and December 2017 it was determined the facility failed to ensure Employee Identifier (EI) # 10 Dietitian, reviewed and approved each menu for each patient which was completed by EI # 7, Dietary Manager. This had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Diet Manual
PCMC Nutritional Services
Effective Date: 8/08
Revised 9/11

Policy: The PCMC Diet Manual is adopted and approved by the Medical Staff for use as a reference for nutritional care.

Procedure:
A. The diet manual will serve as a guide for ordering diets and patient menus/meals will be consistent with the guidelines in the manual.

B....The manual assits the Clinical Dietitian in providing optimal nutritional care and education to the patient....

H. The approved diet manual will be located on the PCMC intranet and on Meditech.

***
Policy: Subject: Substitute Food Items
PCMC Nutritional Services
Effective Date: 12/10
Revised 9/11

Purpose: substitutions are occasionally unavoidable. If it is necessary to make a substitution for an item that is on the menu, it is important that the substituted item is similar to the item that is not available.

Policy: Every effort will be made to provide the food items as they are listed on the menu. In the event that an item is not available, an item of similar nutritive value will be substituted.

Procedure:
A. When an employee notices an out of stock item, they will bring it to the attention of their Manager.

B. The Manager, in consultation with the Dietitian if necessary, will agree on an appropriate substitute....

D. At no time should an employee randomly substitute an item.

***
Policy: Subject: Medical Nutrition Therapy-Nutrition Assessment
PCMC Nutritional Services
Effective Date: 03/99
Revised Date: 09/11

Purpose: To develop a plan of care for patients identified at nutritional risk.

Policy: All patients identified at nutritional risk will be assessed by the dietitian depending on the patients nutritional needs...

Procedure:
A. The dietitian is notified via computerized message that the physician has requested a nutritional assessment...

C. A nutritional assessment will be completed by a dietitian depending on the patients nutritional needs...

D. The assessment will be documented in the computerized medical record on the Clinical Nutrition Screen/Assessment...

F. Appropriate recommendations will be made by the dietitian based on the patient's assessment. The dietitian may set up nourishments as appropriate...

I. All assessments will be recorded in Nutritional Services Patient Logbook located in the Director of Nutritional Services Office.


1. EI # 10 was hired as a part-time Dietitian for the Pickens County Medical Center (PCMC) on 3/6/15.

On 1/9/18, during the tour of the kitchen, the surveyor requested the dietitian provide a copy of the diets for the last 2 weeks that had been approved by the dietitian for the facility.

During the interview on 1/10/18 at 10:20 AM, EI # 10 stated there was no record of the diets that were provided to the patient population at the PCMS for the last 2 weeks. The surveyor asked EI # 10 when did he/she review and approve the menu items and menu substitutions, EI # 10 replied that he/she is not involved with the menus or the meals served to the patients.

During the interview on 1/10/18 at 10:40 AM, EI # 10 also stated he/she does not follow the substitutions policy at PCMC. EI # 10 stated the dietary aides take copies of old DCH Season To Please room service menus, that were revised on 6/2013, to the patient's room and allows the patient to select what they would like to eat each meal. The diet aide then inputs the selections in the Dietary Computer C-BORD, a computerized dietary planner, then follows the computerized dietary planner. The dietitian is not consulted about the selections that are put into C-BORD.

During the interview on 1/10/18 at 10:40 AM, the surveyor asked EI # 10 how he/she ensured the meals served to the patients at PCMC were based on the Recommended Daily Allowances (RDA) and were nutritionally balanced for the patients, EI # 10 replied that he/she does not do that.

The surveyor asked EI # 10 who makes the decision as to what meals the patients received and he/she stated the kitchen staff (cooks and dietary aides), non-licensed personnel.

The surveyor asked EI # 10 if he/she was consulted by the Dietary Manager about which food items to include on the menu and he/she stated that he/she does not participate in any consultations related to the menus.

The surveyor asked EI # 10 if he/she provided any collaboration with other hospital services or had any input into the Quality Assurance program in the hospital and he/she stated he/she did not.

On 1/10/18 at 1:30 PM, the surveyor asked EI # 9, Cook, to demonstrate the C-BORD input of a diabetic diet meal plan for breakfast. EI # 9 explained that the items that are red in color are not a part of the patients dietary plan. The surveyor asked EI # 9 to select a red item, then an alert popped up asking if he/she was sure he/she wanted to add the item. The surveyor instructed EI # 9 to select "yes". The red item was allowed to be selected although it was not a part of that patients dietary plan.

An interview was conducted on 1/10/18 at 10:20 AM with EI # 10 and an interview on 1/11/18 at 5:40 PM with EI # 7, who confirmed the above mentioned findings.

Based on review of policies and procedures, personnel files and staff interviews, the facility failed to have their personnel oriented and deemed competent in their respective dietary duties. This deficient practice had the potential to negatively affect all patients receiving meals from the hospital dietary department.

Findings include:

Policy: Subject: New Personnel Training and Education Program
Pickens County Medical Center (PCMS)
Department: Nutritional Services
Effective Date: 03/99
Reviewed: 09/11

Purpose: To establish procedures that will be used to orient newly hired PCMC (Pickens County Medical Center) Nutritional Services employees to the Nutritional Services Department.

Policy: "All new employees will participate in the PCMC hospital-wide orientation as well as a Nutritional services Department orientation.

Responsibilities:
1. The Director of Nutritional Services has the ultimate responsibility for ensuring each employee obtains both orientations.

2. The Supervisor/designee will be responsible for scheduling the orientation programs and assisting in the departmental orientation as indicated.

Procedure:

1. The Supervisor/designee will provide the departmental orientation on the first day of work....

3. An evaluation of the orientation program will be completed by each newly oriented employee at the end of the orientation. The evaluation form will be provided to the employee after the orientation process has been completed. The information will be used to recommend changes in the orientation program.

4. All orientation evaluations will be maintained in the Education Coordinator's office.

***
Policy: Subject: On-The-Job-Training (OJT) Program
PCMS
Department: Nutritional Services
Effective Date: 08/08
Reviewed: 09/11

Purpose: To establish a standardized procedure for conducting OJT in the Nutritional Services Department.

Policy:

1. The Director of Nutritional Services has ultimate responsibility to ensure each employee obtains appropriate OJT.

Procedure:

1. All new employee trainees are assigned to work side-by-side a competent individual who has has prior training and experience.

2. Employee trainees are again oriented to their work area in more detail with their trainer performing the function....

4. The trainer works with the trainee until competency is demonstrated.

5. Competency validation will begin upon hire and be completed within the 90 day probation period to the extend possible utilizing Demonstration, Cognitive Test, Observation and Self Study Packet.


1. Employee Identifier (EI) # 7, Dietary Manager, was hired in this new position at the Pickens County Medical Center (PCMS) on 7/27/14.

Review of the personnel file for EI # 7 was conducted with the assistance of EI # 8, Director of Human Resources, on 1/11/18 at 12:00 PM, revealed no documentation of dietary orientation, dietary competency and no job description for the Dietary Manager for EI # 7.

2. EI # 9, Cook, was hired at the PCMS on 5/16/18. As the Cook, he/she is the direct supervisor for the Dietary Aides.

Review of the personnel file for EI # 9 was conducted with the assistance of EI # 8, on 1/11/18 at 12:00 PM, revealed no documentation of dietary orientation, OJT documentation, or documentation for the competency of using the C-BORD, a computerized dietary planner.

3. EI # 10 was hired as a part-time Dietitian at PCMC on 3/6/15.

Review of the personnel file for EI # 10 was conducted with the assistance of EI # 8, on 1/11/18 at 12:00 PM, revealed no documentation of dietary orientation, or documentation for the competency of using the C-BORD, a computerized dietary planner.

4. EI # 11, Dietary aide, was hired at the PCMC on 3/16/05.

Review of the personnel file for EI # 11 was conducted with the assistance of EI # 8, on 1/11/18 at 12:00 PM, revealed no documentation of dietary orientation, OJT documentation, or documentation for the competency of using the C-BORD, a computerized dietary planner

5. EI # 12, Dietary aide, was hired at the PCMC on 3/30/09.

Review of the personnel file for EI # 12 was conducted with the assistance of EI # 8, on 1/11/18 at 12:00 PM, revealed no documentation of dietary orientation, OJT documentation, or documentation for the competency of using the C-BORD, a computerized dietary planner

An interview was conducted on 1/11/18 at 6:10 PM with EI # 3, Director of Nursing, who confirmed the aforementioned findings.

Based on review of facility policies and procedures and staff interviews, it was determined the facility failed to ensure that all diets met the nutritional needs of the patients and provided the Recommended Daily Allowances (RDA). This had the potential to negatively affect all patients admitted to the facility.

Findings include:

Policy: Subject: Medical Nutrition Therapy-Nutrition Assessment
PCMC Nutritional Services
Effective Date: 03/99
Revised Date: 09/11

Purpose: To develop a plan of care for patients identified at nutritional risk.

Policy: All patients identified at nutritional risk will be assessed by the dietitian depending on the patients nutritional needs...

Procedure:
A. The dietitian is notified via computerized message that the physician has requested a nutritional assessment...

C. A nutritional assessment will be completed by a dietitian depending on the patients nutritional needs...

D. The assessment will be documented in the computerized medical record on the Clinical Nutrition Screen/Assessment...

F. Appropriate recommendations will be made by the dietitian based on the patient's assessment. The dietitian may set up nourishments as appropriate...

I. All assessments will be recorded in Nutritional Services Patient Logbook located in the Director of Nutritional Services Office.


1. A interview was conducted on 1/10/18 at 10:10 AM with EI # 10, Dietitian. The surveyor asked EI # 10 what was his/her input with the diet and menu selections that are served to the patient population. EI #10 stated he/she had no input on the diet selections, substitutions or menus that are used in the dietary department. He/she stated the patient selections come from old DCH Season to Please Room service menus that she had no input in writing.

The surveyor asked EI # 10 how he/she ensured the meals served to the patients at PCMC were based on the Recommended Daily Allowances (RDA) and were nutritionally balanced for the patients, EI # 10 replied that he/she does not assess the nutritional value of the meals served to the patients.

An interview was conducted on 1/11/18 at 5:40 PM with EI # 7, Dietary Manger, who confirmed the above findings.

Based on review of facility policy and interview with facility staff, it was determined the facility failed to have an approved current therapeutic manual available to all staff according to the facility policy.

Findings include:

Policy: Diet Manual
PCMC Nutritional Services
Effective Date: 8/08
Revised 9/11

Policy: The Pickens County Medical Center (PCMC) Diet Manual is adopted and approved by the Medical Staff for use as a reference for nutritional care.

Procedure:
A. The diet manual will serve as a guide for ordering diets and patient menus/meals will be consistent with the guidelines in the manual.

B....The manual assist the Clinical Dietitian in providing optimal nutritional care and education to the patient....

H. The approved diet manual will be located on the PCMC intranet and on Meditech.
*****

An interview was conducted on 1/10/18 at 10:10 AM with Employee Identifier (EI) # 10, Dietitian. The surveyor requested documentation that the dietitian used and had access to a current diet manual. EI # 10 stated he/she is unable to access a current diet manual on the computer and there was no paper manual in the facility. EI # 10 provided the surveyor with the aforementioned PCMC Diet Manual policy but was unable to produce the facility's approved and updated Dietary Manual. EI # 10 stated " I can not access the manual on the intranet and I don't know who to ask".

An interview was conducted on 1/11/18 at 5:40 PM with EI # 7, Dietary Manager, who confirmed the above findings.

Based on review of facility policy and procedure, observations and interviews, it was determined the staff failed to document preventive maintenance (PM) inspection on all equipment in the Radiology Department. This had the potential to negatively affect all patient's served by this facility.

The findings include:

Subject Title: Quality Assurance Inspection (preventive Maintenance)
Revised date: 8/29/16

Policy:

All equipment included in the Bio-medical equipment management program shall be subject to periodic Quality Assurance inspection (QAI) as outlined in this policy...

Purpose:

To establish and maintain an ongoing QAI program on all equipment within the Bio-Neducak Equipment Management Program (EMP), except equipment excluded...

Procedure:

All equipment not excluded by the EMP receives a QAI at least annually..."

******

An observation of the Radiology Department was made on 1/10/18 at 10:41 AM. There were no Biomed Sticker or other documentation available to ensure the following Radiology equipment had been checked for hazards:

RAD (Radiology) RM (Room) # 1 - GE SFX II (General X-Ray)

During an interview with a Employee Identifier (EI) # 16, Radiology Director on 1/11/18 at 2:41 PM, EI # 16 verified there were no Biomed stickers on the equipment and no preventive maintenance had been performed on the equipment listed above.

An observation of the Outpatient Services was made on 1/10/18 at 12:30 PM. There were no Biomed Stickers or other documentation available to ensure the following Outpatient Services equipment had been checked for hazards:

RM # 1:

Scale - Last PM performed 6/2016

Blood Pressure Machine - Last PM performed 6/2016

Cast Remover - Last PM performed 6/2016

RM # 3:

X-Ray Film View (View Box) - Last PM performed 6/2014

RM # 4:

View Box - Last PM performed 6/2014

RM # 5:

View Box - Last PM performed 6/2014

Hallway between RM # 5 and 6:

View Box - Last PM performed 6/2014

An interview was conducted on 1/10/18 at 12:30 PM with EI # 5, Nurse Manager - Surgical Services who confirmed the above findings.

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

1) Performed hand hygiene after removing used gloves the donning clean gloves.

2) Followed isolation procedures and protocols.

This deficient practice could have a negative affect on all patients served by the hospital.

Policy: Hand Hygiene
Policy #: IC 109
Revised date: 6/2017

II. Statement of Policy
It is the policy of Pickens County Medical Center (PCMC) as recommended by the Centers for Disease Control (CDC) that health care workers was their hands with either a non- microbial soap (plan soap) and water or an antimicrobial soap and water when their hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids. If hands are not visibly soiled, an alcohol based hand rub (ABHR) can be used.
1. Hands should be decontaminated either by handwashing or use of ABHR 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:

After contact with inanimate objects in the immediate vicinity of the patient.
After removing gloves.

The use of gloves does not eliminate the need for hand hygiene, likewise, the use of hand hygiene doe not eliminate the need for gloves.

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Policy: Isolation Precautions
Policy #: IC 106

Policy:
A. It is the of the Pickens County Medical Center to isolate patients diagnosed with or being evaluated for communicable disease or epidemiologically significant organisms (example, Methicillin Resistant Staphylococcus Aureas (MRSA), Vancomycin Resistant Enterococci (VRE), Clostridium Difficile, Influenza, Tuberculosis (TB) and so forth (etc.). Isolation Precautions for patients with specific disease and organisms are used in addition to Standard Precautions. ...

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:

Droplet Precautions (Green Sign)
Droplet Precautions are used for a patient known or suspected to be infected with microorganism transmitted by droplets than can be generated by the patient during sneezing, coughing, talking or the performance of procedures involving respiratory tract. ...

Procedure For Isolation.

2. Educate the patient/ designated representative regarding isolation precaution specifics.

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Policy:

Procedure Decentralized Lab Testing

I. Goal:

To provide accurate blood glucose monitoring by finger stick.

II. Objective:

To monitor blood glucose levels quickly and accurately at the bedside...

4. Proper hand hygiene by individuals performing the test and cleaning of the meter with alcohol should be performed after every use...

B. Cleaning of the Precision Xtra blood glucose monitor:

Daily and after each patient use, cleaning of the machine with alcohol should be performed..."

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1. During an observation with Employee identifier (EI) # 4, Registered Nurse (RN) conducted on 1/9/18 at 2:30 PM to observe EI # 4 administer patient's feeding of Isosource 250 milliliters (ml)/ 1 can of Isosource and 200 ml of water (through a Percutaneous Endoscopic Gastrostomy (PEG). EI # 4 performed hand hygiene prior to donning clean pain of gloves, aspirated fluids from the PEG tube and obtained 50 ml of residual and was discarded. EI # 4 removed used gloves and don on clean gloves without performing hand hygiene and proceeded to administer the 250 ml of Isosource then followed by the 200 ml of water. EI #4 went to the patient's bathroom to rinse the syringe used for feeding, removed used gloves and don on new clean pair of gloves without performing hand hygiene.

In an interview conducted on 1/11/18 5:45 PM with EI # 3, Director of Nursing/ Infection Control Nurse (DON/ ICN) who confirmed the above mentioned findings.



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2. An observation of medication administration for PI # 13 was conducted on 1/9/16 at 11:10 AM with EI # 13, RN. During this observation, EI # 13 sanitized his/her hands outside the patient's room and donned gloves after entering the patient's room without performing hand hygiene.

EI # 13 performed a blood glucose check using a glucose meter. EI # 13 used a lancet to obtain the patient's blood and applied it on a test strip inserted inside of the glucose meter. EI # 13 completed the blood glucose check and discarded the used supplies. EI #13 use the same gloves to clean the glucose meter. EI # 13 failed to remove gloves, sanitize hands, and don clean gloves before cleaning glucose meter for the next patient use.

EI # 13 left PI # 13's room and enter an unsampled patient's room. EI # 13 used the glucose meter to check the unsampled patient's blood glucose without cleaning per policy.

An interview was conducted on 1/11/18 at 6:08 PM with EI # 1, Director of Quality Management who confirmed the above findings.

3. An observation of medication administration for PI # 13 was conducted on 1/9/16 at 11:20 AM with EI # 13, RN. During this observation, EI # 13 sanitized his/her hands outside the patient's room and donned gloves after entering the patient's room without performing hand hygiene.

EI # 13 entered PI # 13's room with PI # 13's insulin and a unsampled patient's insulin. EI # 13 placed the unsampled patient's insulin syringe on PI # 13's tray table. EI # 13 administered PI # 13's insulin. EI # 13 proceeded to the unsampled patient's room and administered the unsampled patient's insulin.

An interview was conducted on 1/11/18 at 6:08 PM with EI # 1 who confirmed the above findings. EI # 1 stated EI # 13 should have stored the unsampled patient's insulin inside of a plastic baggie inside of the COW (medication cart) instead of placing it on another patient's tray table.



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4. On 1/10/18 at 12:00 PM, the surveyor accompanied EI # 11, dietary aide, to the medical unit to observe passing out lunch trays. EI # 11 noticed a green droplet precautions sign on the door of room 204 and stated the sign was not on the door at breakfast nor was he/she told by the floor staff the patient was in isolation when he/she delivered the breakfast tray.

EI # 11 also stated there was no indication on the printed diet roster the patient was on droplet isolation.

The surveyor noted an isolation cart, with multiple drawers with labels on the outside of it sitting outside of room 204. EI # 11 placed the patients lunch tray on top of the cart.

The surveyor asked a visitor that was sitting outside of the room 204 had he/she been instructed by the staff on which PPE (Personal Protective Equipment) from the isolation cart was required to enter into the room and he/she stated he/she had not been instructed.

The surveyor reviewed the chart of the patient in room 204 and noted the patient was admitted to the facility on 1/8/18 with diagnosis of Pneumonia and was placed in droplet isolation because of influenza.

During the interview on 1/11/18 with EI # 3, Infection Control Coordinator (ICC), confirmed the above findings and stated the ICC was not contacted about the patient requiring isolation but the patient should have been placed on isolation on 1/8/18 when admitted to the medical floor instead of being delayed until 1/10/18.

Based on review of documentation and interview, the facility failed to provide documentation of testing and training per the requirements of the facility's Emergency Preparedness Program.

An interview was conducted on 1/11/18 at 5:00 PM with Emergency Preparedness Coordinator/ Director of Nursing (DON) who stated that the hospital had not been able to establish connection and communication with other entities to do emergency preparedness training and testing.

Based on review of the Emergency Preparedness (EP) Program and interview with the agency staff, it was determined the facility failed to conduct EP program to its current and active staff members.

An interview conducted on 1/11/18 at 5:00 PM with Employee Identifier (EI) # 3, EP Coordinator/ Director of Nursing (DON) stated that the facility have not conducted training and testing on the hospital staff.