HospitalInspections.org

Based on observations and interviews with staff during a tour of the hospital by Life Safety Code surveyors, it was determined the hospital was not constructed, arranged and maintained to ensure patient safety.

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

Findings include:

Refer to tags: K-0226, K-0351, K-0363, K-0781, K-0211, K-0226, K-0353, K-0372, K-0345, and K-0712.

Based on medical record (MR) review, hospital policy, and interviews with staff, it was determined the hospital failed to ensure the hospital policy for skin assessment including wound measurements were followed.

This deficient practice did affect three of nine MRs reviewed with wounds, including Patient Identifier (PI) # 18, PI # 3, and PI # 1, and had the potential to negatively affect all patients admitted to the hospital with wounds.

Hospital Policy: Skin Assessment

Policy Number: Not documented

Revised: 3/25/25

Purpose: To establish guidelines for skin assessment and treatment options.

Policy:

Patient skin assessment should be completed ...upon admission and at a minimum of every shift ...or as indicated ...documentation in the electronic medical record...should be documented...upon admission ...flowsheet should be updated.

...5. The Wound Care Nurse or nurse who is specially trained and competent should measure wounds at the time of consult and within the next week or on subsequent visits as indicated by the patient condition...

Findings include:

1. PI # 18 was admitted to the hospital on 3/12/25 with a diagnosis of Acute Hypoxic Respiratory Failure.

Review of the primary nurse documentation dated 3/16/25 revealed a medial coccyx, unstageable pressure ulcer (PU).

Review of the Physician's Order dated 3/16/25 at 12:11 AM revealed orders for the Wound Care Nurse to assess coccyx wound.

Review of Employee Identifier (EI) # 16, Wound Care Nurse, Televisit assessment, dated 3/16/25 at 5:19 AM revealed documentation of an unstageable PU. There was no documentation of wound measurements.

An interview was conducted on 4/24/25 at 2:12 PM with EI # 3, Director of Nursing, who confirmed the agency failed to ensure wound measurements were completed per hospital policy.



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2. PI # 3 was admitted to the hospital on 6/29/24 with diagnoses including Acute Respiratory Failure, Severe Obesity, PU left (L) heel and sacrum, and Chronic wound right (R) lower extremity.

Record review revealed wound care orders dated 6/29/24 for routine daily care, Mepilex dressing to a sacral stage 2 decubitus ulcer, saline wet-to-dry dressing R lower leg wound, and L heel wound, heel protectors if possible.

Review of the nurse documentation dated 6/29/24 revealed a sacral PU, a perineum PU, and an arterial ulcer on the R posterior calf. There was no nursing assessment documentation of a L heel PU. There were no wound measurements documented for any wound.

Review of the 6/30/24, 7/2/24, and 7/3/24 nurse documentation revealed no documentation of wound measurements.

Review of the 7/1/24 nurse documentation revealed no wound assessments, no wound measurements, and no documentation wound care was provided.

An interview was conducted on 4/24/25 at 2:34 PM with EI # 12, Medical Surgical /Intensive Care Manager, who confirmed there was no documentation wounds were measured, wounds were not assessed each shift per policy, and wound care was not provided daily as ordered.

3. PI # 1 was admitted to the hospital on 4/20/25 with diagnoses including Altered Mental Status, and recent Fall.

Review of the 4/20/25 Emergency Department record documentation revealed the presence of a sutured laceration below the L eye, and bruising with skin tears to the L shoulder, and L knee.

Further record review revealed wound orders dated 4/20/25, apply Bactroban 2 % to face, L knee, and L shoulder topically twice daily for seven days.

Review of the nurse documentation dated 4/20/25 revealed no documentation the skin tears were measured.

Review of the nurse documentation dated 4/21/25 revealed no documentation of wound assessments to the L shoulder or L knee skin tears.

Review of the nurse documentation dated 4/22/25 at 6:00 AM revealed the presence of a R anterior knee skin tear. There was no wound assessment, and no wound measurements documented.

Staff failed to conduct wound assessments every shift and document wound measurements at least every week per hospital policy.

An interview was conducted on 4/24/25 at 2:08 PM with EI # 12, who confirmed staff failed to follow the hospital policy for wound assessment and measurements.

Based on observation, hospital policy and procedure, Diversey J-512 Sanitizer, manufacturer directions for use (MDFU), and staff interviews, it was determined the facility failed to ensure staff followed the policy and the MDFU of the sanitizing solution. This had the potential to negatively affect patients, staff, and visitors.

Findings include:

Hospital Policy: Sanitizing Food Contact Surfaces
Policy Number: F018
Date Reviewed: 3/24

Policies:

...Sanitizer solution must be at 200 ppm (parts per million) for J-512 Sanitizer.

Procedures:

...Refer to the Diversey Product Guide for appropriate chemicals for...sanitization.

...Pot Sink:

...Immerse items in sanitizing solution for a minimum of 60 seconds...

Diversey J-512 Sanitizer

Use Instructions

...For Sanitization:

To Sanitize Hard, Non-Porous Food Contact Surfaces and Equipment:

...3. Apply sanitizing solution by immersion...as appropriate to the equipment or surfaces to be treated. Allow a contact time of at least one minute...

1. An observation was conducted on 4/22/25 at 12:45 PM at the three compartment sink for sanitization of the cookware with Employee Identifier (EI) # 9, Cook.

An interview was conducted on 4/22/25 at 12:50 PM, during the observation, with EI # 9. EI # 9 was asked how long the cookware should remain in the third bin sanitizer in the three compartment sink. EI # 9 reported, "10-15, maybe 20 seconds."

The surveyor observed EI # 9, wash, rinse, and sanitize three pans, three tong utensils, and a measuring cup, for a total of seven items. EI # 9 failed to allow each piece of cookware at least a one-minute immersion time in the sanitizer.

An interview was conducted on 4/23/25 at 3:25 PM with EI # 11, Clinical Nutrition Manager. EI # 11 confirmed all cookware was not immersed in the Diversey sanitizing solution for the minimum 60 seconds per hospital policy and the Diversey J-512 MDFU.

Based on review of the hospital Emergency Preparedness Operations Plan (EOP) documentation, and interviews with staff, it was determined the hospital failed to ensure all off site locations were included in a comprehensive emergency preparedness program. This affected one of the six offsite locations, including North Baldwin Infirmary (NBI) Infusion Center, and had the potential to negatively affect all patients, staff, and visitors at the outpatient clinic.

Findings include:

Review of the hospital EOP documentation last reviewed 8/15/24, revealed the program scope was designed for NBI facilities.

There was no documentation The Infusion Center, an offsite location, was included in the NBI EOP plan.

An interview was conducted on 4/24/25 at 9:30 AM with Employee Identifier (EI) # 14, Manager, Protective Services, and EI # 15, Facility Compliance/Safety Manager, which confirmed the hospital had six offsite outpatient clinics under the facility provider number. EI # 14 reported there was an outpatient clinic, NBI Infusion Center, located greater than 20 miles away, in Daphne, Alabama. EI # 14 reported he/she recently learned the Infusion Center, was under the NBI provider number.

An interview was conducted on 4/24/25 at 11:50 AM with EI # 15, who confirmed the Infusion Center, located in Daphne, was opened in 11/2023, and was not included in the NBI EOP.

Based on review of contracted service personnel files, and interview with staff, it was determined the hospital failed to ensure contracted staff received training on Emergency Preparedness (EP) a minimum of every two years.

This affected two of two contracted service employee files reviewed and had the potential to affect all persons served by the hospital.

Findings include:

Review of the dietary staff personnel files provided revealed no documentation Employee Identifier (EI) # 9, Cook, date of hire (DOH) 6/24/24, completed initial EP training.

Review of EI # 10, Food Service Worker, DOH 11/4/16, personnel file documentation, revealed last EP training was 7/2020, which was greater than every two years.

An interview was conducted on 4/25/25 at 10:40 AM with EI # 11, Clinical Nutrition Manager, Contracted Service, who confirmed there was no documentation the two employees had current EP training.