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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 interview the hospital failed to establish an institutional plan or budget to include all anticipated income and expenses, capital expenditures for a three year period and anticipated sources of financing. The failure affected the whole hospital and had the potential to affect all patients served.Findings include:On 6/29/15 at 3:15 PM, survey staff requested a copy of the hospital's budget from Employee Identifier (EI) # 2, Administrator. EI # 2 stated he/she spoke with the hospital's Chief Financial Officer (CFO) who informed her the hospital did not have a budget. Survey staff requested EI # 2 to ask the CFO again if the hospital had an institutional budget.On 6/30/15 at 9:48 AM, survey staff asked EI #2 if the CFO ever located a budget. EI # 2 stated the hospital did not have a budget.

Based on medical record review, hospital policy and an interview the hospital failed to document other means attempted to prevent the use of a restraint on Medical Record (MR) # 28 prior to the application of a chest restraint (Posey Vest). This affected 1 of 2 medical records reviewed for restraints and had the potential to affect all patients served.Findings include:Medical Record # 28 was seen in the hospital Emergency Room on 4/30/15 with a diagnosis to include Altered Mental Status, Syncope and Muscle Spasm. A review of the Emergency Room nurses notes at 11:30 PM, documented, " Patient handcuffed secondary to hostile behavior. " There was no documentation of who placed the handcuffs on MR # 28, when handcuffs were placed (prior to arrival or after arrival to the hospital), who was monitoring MR # 28 while in handcuffs, and what other least restrictive measures had been attempted but failed prior to the use of the handcuffs. On 7/01/15 at 8:45 AM, Employee Identifier (EI) # 1, Director of Nursing was interviewed about MR # 28 ' s chart. EI # 1 stated the police placed the handcuffs on MR # 28 prior to his/her arrival to the hospital and stayed with the patient while handcuffs were on him/her. EI # 1 also confirmed there was no documentation in the medical record of where staff attempted other means to prevent MR # 28 from harming self or others prior to the application of the posey vest restraint. A physician order for a posey vest restraint was received on 4/30/15 at 10:42 PM.Hospital Policy number 611.37, Restraints states:" Restraints are to be used for patient safety purposes when all other means to prevent injury to self or others have failed. Other means include but are not limited to:1. Frequent orientation and instructions regarding safety (side rails, use of call bell for assistance, ect.), the importance of maintaining lines and tubes, ect.2. Review of medications, which may contribute to confusion and disorientation and appropriate physician notification.3. Allowing family members/significant others to remain with patient.4. Administration of medications to reduce agitation, anxiety after physician notification and orders. "Hospital approved restraint devices include:1. Chest restraint (Posey vest)2. Soft wrist restraint3. Soft ankle restraint4. MittensHospital staff failed to attempt least restrictive measures prior to the application of a chest restraint to MR # 28.

Based on medical record review and interview, the hospital failed to document the rationale and specific duration of time for restraint use for Medical Record (MR) # 21. This affected one of two medical records reviewed for restraint use.

Findings Include:

Based on a review of MR #21 prn (as needed) restraint orders were written on the following dates:

5/27/15 at 17:18: "Soft restraint to rt. (right) arm PRN x 24 hours.

5/28/15 at 8:16 AM: "Soft restraints prn."

During an interview on 7/1/15 at 2:45 PM, the Director of Nursing , EI # 1, stated restraint orders should not be written prn (as needed).

Based on record review and an interview the hospital staff failed to remove a posey vest restraint once the patient was calm. This affected 1 of 2 records reviewed for restraint use and had the potential to affect all patients served.Findings include:Medical Record (MR) # 28 was admitted to the hospital on 4/30/15 with Altered Mental Status, Syncope and Muscle Spasm. The physician order for restraint dated 4/30/15 at 10:42 PM documents, " Use posey vest for patient safety x (times) 1 - 2 hrs (hours)". The nursing notes dated 5/01/15 at midnight document, " Vest restraint placed on pt (patient) as ordered, will cont (continue) to monitor, call light remains in reach, mother at bedside. " At 2:15 AM, MR # 28 was given Haldol 5 milligrams (mg). At 4:00 AM, nursing staff documented posey jacket checked and intact, patient appears to be asleep. At 5:05 AM, nursing staff documented, " Active in bed w (with) posey off, sleeping at the foot of the bed. Pt repositioned in bed, posey jacket replaced, pt back to sleep. " At 7:41 AM, nursing staff documented MR # 28 ' s psychosocial behavior pattern as appropriate, cooperative and compliant with treatment, posey vest intact and caretaker present in room. At 1:30 PM, nursing staff documented MR # 28 was transferred in stable condition to another hospital. On 7/01/15 at 8:45 AM, Employee Identifier (EI) # 1, Director of Nursing (DON) was interviewed. During the interview EI # 1 was asked why the restraint was not removed from MR # 28 when staff documented he/she was asleep and compliant with treatment. EI # 1 reviewed the record and did not know why staff failed to remove the restraint earlier.

Based on record review, review of hospital policy and an interview the hospital failed to monitor Medical Record (MR) # 28 while placed in a chest restraint (Posey Vest). This affected 1 of 2 records reviewed for restraints and had the potential to affect all patients served. Findings include:Medical Record # 28 was admitted to the hospital on 4/30/15 with a diagnosis to include Altered Mental Status, Syncope, and Muscle Spams. On 4/30/15 at 10:42 PM the physician ordered the use of a posey vest for patient safety for 1 to 2 hours. A review of the nursing notes documents at 10:30 PM, MR # 28 was very restless and combative. Ativan 1 milligram was given and vest restraint ordered. Nursing notes dated 5/01/15 documented the following:Midnight - vest restraint was placed on MR # 28 as ordered. 2:00 AM - restraint/posey jacket checked.4:00 AM - posey jacket checked and intact.5:05 AM - posey off, sleeping at the foot of the bed. Patient repositioned in bed, posey jacket replaced, patient back to sleep. 7:41 AM - Posey vest intact.1:30 PM - Patient transferred.A review of the hospital policy, 611.37, Restraints failed to include the frequency patients were to be monitored by staff while in a restraint. On 7/01/15 at 8:45 AM, Employee Identifier (EI) # 1, Director of Nursing (DON) was interviewed about MR # 28. EI # 1 was asked how often staff were to monitor patients while in restraints and stated at least every 2 hours per hospital policy. EI # 1 also stated monitoring should be documented in the nursing notes.A review of the hospital policy 611.37 for restraints states the following: "Additional nursing care and documentation is necessary with use of restraints, and includes:1. Type of restraint used2. Restraint removal every two hours with range of motion on involved extremity3. Circulation check of involved extremity every two hours4. Hydration and nutrition checks every two hours5. Personal hygiene needs every two hours6. Side rails are to be up at all times"The nursing staff failed to document nursing care and monitoring of MR # 28 while restrained.

Based on review of physician credentialing files and an interview the hospital failed to assure all members of the medical staff were reappointed and recommended for staff privileges. This failure affected 2 of 6 medical staff files reviewed and had the potential to affect all patients served.Findings Include:On 7/01/15 the medical staff credentialing files were reviewed by the surveyor. During the review there was no documentation Physician Identifier (PI) # 1, Internal Medicine, had been reappointed to provide clinical services. PI # 1 ' s medical staff privileges expired April 2014. The credentialing file for Certified Registered Nurse Practitioner (CRNP) Identifier # 1 was reviewed. During the review there was no documentation CRNP # 1 had been reappointed to provide clinical services. CRNP # 1 ' s medical staff privileges expired June 2014.On 7/01/15 at 12:00 noon, Employee Identifier (EI) # 3, Utilization Review, was asked for documentation of where PI # 1 and CRNP # 1 had been reappointed to medical staff and confirmed there was no documentation this had been done.

Based on medical record review, interview and documentation by the Alabama State Board of Health/ Division of Disease Control it was determined the facility failed to ensure all animal bites were reported to the County Health Officer.

This affected Emergency Room (ER) record # 4, 1 of 2 records reviewed with animal bites and had the potential to negatively affect all patients served by the facility with animal bites.

Findings include:

Chapter 420-4-4 Rabies Control Program

"...420-4-4-.04...(1) Who must report. Any health care professional who treats an animal bite or exposure, any professional who has knowledge of an animal bite or exposure, ..."


ER record # 4 presented to the ER 3/14/15 with complaints of a "dog bite". There was no documentation the staff followed up and contacted the local County Health Officer.

An interview conducted 7/1/15 at 1:20 PM with Employee Identifier # 1, Director of Nursing, verified there was no documentation to reveal the animal bite was reported.

Based on record review and an interview the hospital nursing staff failed to document the wound care provided to Medical Record (MR) # 24. This affected 1 of 1 records review for wounds and had the potential to affect all patients served.Findings include:Medical Record # 24 was admitted to the hospital on 3/24/15 with a diagnosis of pneumonia. A review of the physician orders documented 3/24/15 wound care as follows: Santyl twice a day with dressing changes. The physician order failed to state what the wound was to be cleaned with, the location of the wound and dressing to be applied. On admission MR # 24 was assessed to have a surgical wound on the coccyx that measured 5 centimeters (cm) width by 3 cm depth, no length measurement was documented. The type of dressing on admission at 2:50 PM, was documented as Santyl ointment applied to gauze, placed inside wound and covered with an abdominal pad. There was no documentation if the wound was cleaned prior to the dressing application. On 3/25/15 at 6:08 PM, nursing staff documented, " Dressing changed per orders. " There was no specific documentation of the wound bed, old dressing removed, cleaning of the wound and application of the new wound dressing. On 3/26/15 there was no documentation nursing staff provided the twice daily wound care ordered. On 7/01/15 at 8:30 AM, Employee Identifier (EI) # 1, Director of Nursing was interviewed about MR # 24. EI # 1 confirmed nursing staff should document the actual care provided and the physician's order for wound care was incomplete.

Based on observation and an interview the hospital failed to assure all controlled substances were locked to prevent tampering or diversion. This affected the Emergency Department and had the potential to affect all patients served.Findings Include:On 6/29/15 at 2:00 PM, a tour of the Emergency Department was conducted with Employee Identifier (EI) 1, Director of Nursing (DON). During observations of the unlocked medication refrigerator in the Emergency Department a vial of Lorazepam 2 milligrams/milliliter was observed in the refrigerator door. In an interview with EI #1 on 6/29/15 at 2:00 PM, he/she confirmed all controlled medications should be double locked.

Based on observations and interview the hospital failed to assure outdated medications were not available for patient use. This affected the Emergency Department and Pharmacy and had the potential to affect all patients.Findings Include:On 6/29/15 at 2:00 PM a tour of the Emergency Department was conducted with Employee Identifier (EI) # 1, Director of Nursing (DON). During the tour the surveyor observed in the medication refrigerator Promethazine HCL suppository with an expiration date of 10/2014.In an interview with EI # 1, he/she confirmed the medication was expired and removed the medication.On 6/29/15 at 2:35 PM a tour of the Pharmacy Department was conducted with EI # 4, Pharmacy Director. During the tour the surveyor observed 25 vials of Protamine 50 milligrams/5 milliliters with an expiration date of 5/2015. EI # 4 confirmed the medications were expired.



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On 6/29/15 at 2:00 PM a tour of the Emergency Department was conducted with Employee Identifier (EI) # 1, Director of Nursing (DON). During the tour the surveyor observed an opened 30 ml (milliliter) multi dose vial of Cyclobenzaprine without a date of opening. EI # 5, Registered Nurse verified the vial should have been dated when it was opened.

Based on observation and interview, dietary staff failed to label, date and/or discard outdated food items used for patient consumption that was stored in the refrigerator. The double door refrigerator was dripping water and a black colored substance was observed around the interior seal and around the exterior top portion of the deep freezer.

Findings include:

On 6/29/15 at 3:00 PM the following observations were made in the hospital's Dietary Department:

A: Side by Side Refrigerator:

- One carton of pineapple juice dated 2/19;

- Three containers of peaches not dated;

- Three Styrofoam cups that were not dated or labeled;

- A large amount of water was observed dripping from the top of the refrigerator.

- Water observed in several medium sized plastic containers used for condiment storage;

- Standing water was observed on the lids of juice cups.

- No expiration date on individual cups of apple and orange juice;

- One package of hot dogs without open date or expiration date;

- 6 open trays of whole eggs - no date eggs placed in refrigerator and no expiration date;

- Bacon stored in a clear plastic container- no date and no label;

- Poundcake dated 5/21/15 (unknown if date indicates expiration date or date cake placed in refrigerator);

B. Walk in Refrigerator:

- One bucket of pickle spears on the floor (dated 4/23/15-meaning of date unknown);

- One container of nonfat buttermilk expired 6/27/15;

- One gallon container of mayonnaise expired 5/7/15;

On 6/30/15 at 3:00 PM, Employee Identifier, EI # 6, Dietary Staff, confirmed the observations of both refrigerators. EI # 6 emptied water (resulting from the leak in the refrigerator leak) that had collected in several plastic containers used for condiment storage.

On 7/1/15 at 8:10 AM, a black substance was observed around the interior seal and around the top (exterior) of the freezer located in the hall outside the Dietary Department. A build up of ice ( 1 inch) was noted and confirmed by EI # 7, Dietary Staff. The exterior seal was not flush.

During an on 7/1/15 at 8:15 AM , EI # 8, Maintenance Staff, wiped the black substance with his finger and said it's, "Probably dirt from the ice and staff touching it."

Based on observations the hospital failed to assure central venous catheterization kits for adults and pediatric patients were not expired and all sharps containers were not full. This had the potential to affect all patients served.Findings include:During a tour of the Medical floor rooms on 6/29/15 at 1:35 PM, the surveyor observed the sharps container in patient room 104 and room 112 were full.During a tour of the Emergency Department on 6/29/15 at 2:00 PM, the surveyor observed the following expired central venous catheterization kits:Pediatric 2 Lumen kits = 4 with an expiration date of 10/2013Multi Lumen kits(adult) = 2 with an expiration date of 01/2015During a tour of the Laboratory Department on 6/29/15 at 2:25 PM, the surveyor observed the sharps container in the blood bank area was full.

Based on interview the hospital failed to designate a physician as a director of Respiratory Care. This deficient practice has the potential to affect all patients who receive respiratory services because of the lack of physician oversight.

During an interview on 6/29/15 at 1:40 PM, the Director of Nursing, Employee Identifier (EI) # 1, stated the nurses provide respiratory care. There is no Respiratory Therapist on staff.

On 7/1/15 during a review of the Respiratory Therapy Policies and Procedures (P&P's), it was noted none of the P&P's were signed by a physician. The DON confirmed there is no physician director.