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 review of departmental policy and procedure manuals and interview with staff, the facility failed to follow their policy for review of departmental manuals.

Findings include:


During the survey departmental policy manuals to include Nuclear Medicine, Radiology, Rehabilitative Services, Medical Records, Pharmacy, and Surgical Services were reviewed. There was no documentation of an annual review or a review sheet available for review when requested by surveyors.

An interview with Employee Identifier # 1, the Assistant Administrator of Patient Care Services, on 8/31/11 at 7:40 AM confirmed no policy review signature sheet was available for review.

Based on observation, review of the policies and procedures and interview with administrative staff, it was determined the facility failed to ensure:

1. The Senior Care Unit had safe electrical cords for the beds and shower curtains for the patients to use.

2. The Physical Therapy Department maintained the Hydrocollator and paraffin temperatures at a safe temperature.


This had the potential to affect all patients being served by the Senior Care Unit and Physical Therapy Department.


Findings include:

Facility Policy: Moist Hot Packs

V. Procedure:

E. Hot packs will be kept in Hydrocollator when not in use at a temperature of approximately 160 degrees F (Fahrenheit) but not more than 170 degrees F.

Review of the attached log to this policy revealed a space for daily entry for the temperature of the Hydrocollator.

Facility Policy:

Paraffin

V. Procedure: The paraffin temperature should be in a range of 118 to 130 F.

Review of the attached log to this policy revealed a space for daily entry for the temperature for the paraffin.



On 8/30/11 at 11:00 AM, the surveyor conducted a tour of the Senior Care Unit of the hospital.

The following was observed:

In room #s 238, 236, 234, and 233 were electrical cords that were used for the electrical beds which were at least 6 feet long. The surveyor asked Employee Identifier (EI) # 9, the Director of the Senior Care unit, why the electrical cords were not secured and the response was, "they are suppose to be secured".

The shower areas in rooms 238, 237, 236, 235, 234, and 233 contained shower curtains that did not breakaway which left a hazard in which a patient could harm themselves.

The surveyor asked EI # 9 if she/he could breakaway the shower curtains and EI # 9 could not breakaway the shower curtains.

A tour of the Physical Therapy Department was conducted on 8/31/11 at 9:30 AM. The surveyor observed the use of hydro packs on several of the patients. The surveyor then requested the temperature logs for the Hydrocollator and the paraffin baths and none could be provided.

An interview with EI # 11, the Director of Physical Therapy was conducted 8/31/11 at 10:00 AM. The surveyor asked if the department should have been keeping a daily log on the Hydrocollator and paraffin temperatures and the response was, "yes".

Based on observation, interviews and review of the facility's policy, it was determined the facility failed to ensure the pharmacy department kept an accurate record of the distribution of controlled drugs. This had the potential to affect all patients using pharmacy services.

Findings include:

Facility Policy: Controlled Substance Dispensing

I. Purpose:

A. To provide maximum control of movement of controlled substances.

D. To provide pharmacy with a system for maintaining the perpetual inventory of controlled substances and tracking the receipt and distribution of controlled substances.

II. Policy:

It is the policy of Pickens County Medical Center, Pharmacy Department that mechanisms are in place to provide efficient dispensing, storage, billing and security of controlled substances.

III. Procedure:

D. Each item issued shall be signed out of the pharmacy perpetual inventory by recording the floor area to which the drugs are issued, the quantity issued, the new balance and the initials of the pharmacist or technician.

E. At the time of issue, the new balance in the pharmacy perpetual inventory should be verified for correctness. A check mark by the initials on the inventory log shall indicate that the count was checked and is correct.

A tour of the pharmacy department was conducted on 8/31/11 at 8:10 AM. The surveyor and Employee Identifier # 10, Director of the Pharmacy conducted a narcotic count for Demerol 100 mg (milligrams) syringes. EI # 10 counted the # of Demerol 100 mg syringes and stated, "I have 80". The surveyor then looked at the controlled substance log under Demerol 100 mg and saw the pharmacy was to have had 100. The surveyor asked where the other 20 Demerol 100 mg were and the response was they would have to find them. After approximately 5 to 10 minutes EI # 10 showed the surveyor where 20 Demerol 100 mg was taken to the floor on 3/30/11.

An interview with EI # 10 was conducted on 8/31/11 at 8:30 AM. The surveyor asked if the controlled substance log should have read there were 80 Demerol 100 syringes and the response was, "yes'.

Based on observations and interview with facility staff, it was determined the facility failed to assure that all medications available for patient use in the Emergency Room (ER) were not expired. This had the potential to affect all patients.

Findings include:

A tour of the ER was conducted on 8/30/11 at 10:30 AM. During this tour the following outdated medications were found:


ER Treatment Room # 6
Sodium Chloride 45 % (percent) - 1000 cc (cubic centimeter) bag of intravenous (IV) solution times (x) 1 expired (exp) 5/1/11

Medication Room
Dextrose (D) 10 - 500 cc IV x 6 exp 8/1/11
D5 - 250 cc IV solution x 7 exp 7/1/11
D5 - 1000 cc IV solution x 1 exp 6/1/11
D5 with Normal Saline (NS) - 1000 cc IV solution x 1 exp 1/1/11

Trauma Room # 2
D5 - 250 cc IV solution x 2 exp 7/1/11

During an interview conducted on 8/30/11 at 12:45 PM with Employee Identifier # 6, the ER Nurse Manager confirmed the above medications had expired.

Based on observation and interview with facility staff, it was determined the facility failed to ensure safe storage of food items in the dietary department. This had the potential to affect all patients in the facility.

Findings include:

A tour of the Dietary Department was conducted on 8/30/11 at 8:20 AM. During this tour the following salad bar items were not labeled or dated in the walk in refrigerator:
Boiled Eggs
Shredded Cheese
Ham
Bacon Bits
Toss Salad
Mixed Fruit
Salad Mix

During an interview conducted on 8/30/11 at 8:20 AM with Employee Identifier # 7, the Dietary Manager, verified the above salad items were not labeled and did not have a date.

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

1. Assure all medical supplies available for patient use in the Emergency Room (ER) were not expired.

2. Ensure Oxygen was stored properly in the Nuclear Medicine Department.

This had the potential to affect all patients.

Findings include:

1. A tour was conducted on 08/30/11 at 10:30 AM in the ER. The surveyor found the following expired supplies:

ER Treatment Room # 6
Blue Top Laboratory (Lab) Tubes times (x) 7 expired (exp) 7/11
Blue Top Lab Tube x 1 exp 3/11
Secondary Luer-Lock Connector Set x 3 exp 4/11
18 Gauge (GA) angiocaths x 1 exp 6/11
18 GA angiocaths x 4 exp 4/09
16 GA angiocaths x 3 exp 10/09
20 GA angiocaths x 2 exp 6/11
Amniotest Swabs x 16 exp 10/09
Sterile Intravenous (IV) Start Pack x 2 exp 6/1/11

Medication Room
Huber Needle 20 GA x 1 exp 2/11
Secondary Luer-Lock Connector Set x 1 exp 1/11
Small Bore IV Extension Set x 1 exp 3/08

Trauma Room # 2
Cabinet
Frazier Surgical Suction Instrument x 3 exp 5/09
Povidone-Iodine Swabsticks x 4 exp 10/09

Adult Crash Cart
Gastroccult Developer x 1 bottle exp 4/10

Pediatric Crash Cart
20 GA angiocath x 1 exp 2/11
20 GA angiocath x 1 exp 5/11
20 GA angiocath x 1 exp 7/11
Illinois Bone Marrow Needle x 2 exp 11/10
Carbon Dioxide (CO2) Clip x 1 exp 2/11
Straight Thoracic Catheter 36 French x 1 exp 2/10
Burette Medication Set x 1 exp 5/11

During an interview conducted on 8/30/11 at 12:45 PM with Employee Identifier # 6, the ER Nurse Manager confirmed the above supplies were expired.

2. A tour was conducted on 08/30/11 at 9:20 AM in the Nuclear Medicine Department. During the tour, the surveyor observed a portable oxygen tank that was freestanding and unsecured.

An interview was conducted on 8/30/11 at 9:20 AM with Employee Identifier # 8, the Director of Radiology. The surveyor asked if the oxygen tank should be secure and the response was, "yes'.

Based on observations, review of the facility's policies and procedures and interviews, it was determined the facility failed to ensure the staff followed infection control standards in medication administration, whirlpools and for wound care. This had the potential to negatively affect all patients being served by this facility.

Findings include:

Facility Policy: Medical Asepsis

I. Purpose:

To prevent the spread of disease

III. Policy:

e. Never use equipment of one patient on another patient...

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Facility Policy: Standard Precautions

I. Purpose:

C. Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals.

II. Policy:

Standard Precautions - Assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting and apply the following infection control practices during the delivery of health care.

E. Patient-Care equipment and instruments/devices

E.1... Ensure that reusable equipment is not used for the care of another patient until it has been appropriately cleaned and reprocessed and single-use items are properly discarded.

F. Care of the environment

F.1. Clean and disinfect surfaces that are likely to be contaminated with pathogens, including those that are in close proximity to the patient (e.g., beds, bed rails, over bed tables) ...

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Facility Policy: Medication Administration

I. Purpose: To ensure that medications are transcribed, administered, and documented in a safe and efficient manner.

IV. Procedure:

C. Medication Administration

4. All medications are to be administered in an aseptic manner. Wash hands prior to administration and avoid handling the medication.

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Facility Policy for:

Department: Physical Therapy:

Department Policy: Infection Control

General Department Cleaning:

8. The whirlpool will be cleaned after each patient use...

An initial tour was conducted on 8/29/11 at 12:40 PM. The surveyor observed pieces of tape stuck to the side of a whirlpool in the whirlpool room on 2nd floor. Employee Identifier (EI) # 1, the Assistant Administrator of Patient Care Services stated the whirlpool room is not used very often. The surveyor also saw a glove lying on the floor between the whirlpool and the wall. The surveyor asked why the tape was on the whirlpool and the glove was on the floor and no response was given.


The surveyor observed EI # 2 use a pill cutter in Patient Identifier (PI) # 6, PI # 2, and PI # 5 between 8: 20 and 8:50 on 8/30/11 without cleaning between patients.

The surveyor observed EI # 3, the Charge Nurse enter room # 202 (PI # 3) on 8/30/11 at 9:15 AM to administer IV Clindamycin. EI # 3 was not observed to perform hand hygiene before administering Clindamycin per a central IV line.

The surveyor observed EI # 11, the Director of the Physical Therapy Department provide wound care to PI # 3 on 8/30/11 at 10:00 AM. EI # 11 was using the Pulsevac system on PI # 3. EI # 11 removed the wound dressing from the left calf and then the right lower leg with the same gloves. Both dressings had serosanguinous drainage. EL # 11 used a Suction Diverter Wound Tip on a wound to the back of the left calf and then went directly to the wound on the right lower leg with the same Suction Diverter Wound Tip.


A tour of the Physical Therapy Department was conducted on 8/31/11 at 9:30 AM. The surveyor observed several patients complete treatment on a treatment table and the staff would remove linens and replace with clean linen. The surveyor asked EI # 11 when the treatment tables were cleaned and the response was at the end of the day with a Sani-Wipe.

Based on review of medical records, facility policy, the Alabama State Board of Health Chapter 420-4-4 and interview with facility staff, it was determined the hospital failed to follow the reporting requirements to the Alabama State Board of Health in 3 of 5 Emergency Room (ER) records reviewed with animal bites. This affected ER record # 9, # 10 and # 19.

Findings include:

Alabama State Board of Health

Alabama Department of Public Health

Division of Disease Control Administrative Code

Chapter 420-4-4 Rabies Control Program

420-4-4-.04 Reporting Exposures

(1) Who Must Report. Any health care professional who treats an animal bite or exposure, any veterinarian who has knowledge of an animal bite or exposure, and any law enforcement personnel, including animal control officials, who have been informed of or investigated an animal bite or exposure must report the incident.

FACILITY POLICY:
POLICY: Tetanus and Rabies Prevention/Prophylaxis
Emergency Room

..B. Rabies:
Patients admitted to the ER after being bitten by an animal shall be cared for as follows:
...2. Notify Environmentalist Office at Pickens County Health Department...
3. Notify Sheriff's Office, Carrollton, AL (Alabama) to report incident...


1. ER record # 9 came to the ER on 8/16/11 with a dog bite. A review of the medical record revealed no documentation of this incident being reported to the state health department or law enforcement official.

An interview on 8/31/11 at 11: 40 AM with Employee Identifier # 1, the Assistant Administrator of Patient Care Services, confirmed there was no documentation of the dog bite being reported.

2. ER record # 10 came to the ER on 8/21/11 with a dog bite. A review of the medical record revealed no documentation of this incident being reported to the state health department or law enforcement official.

An interview on 8/31/11 at 11: 44 AM with Employee Identifier # 1, the Assistant Administrator of Patient Care Services, confirmed there was no documentation of the dog bite being reported.

3. ER record # 19 came to the ER on 7/27/11 with a dog bite. A review of the medical record revealed no documentation of this incident being reported to the state health department or law enforcement official.

An interview on 8/31/11 at 11: 45 AM with Employee Identifier # 1, the Assistant Administrator of Patient Care Services, confirmed there was no documentation of the dog bite being reported.

Based on an observation of medication administrations, interviews with administrative staff and review of standards of practice and policies and procedures, it was determined the facility failed to ensure:

1. The nursing staff prepared and administered patients' medications in accordance to acceptable standards of practice.

2. There was a policy and procedure that instructed the nursing staff on the correct procedure for pill cutting.

3. The nursing staff followed the facility policy for IV (intravenous) medication preparation and administration.


This affected Patient Identifier (PI) #s 6, 2, 5 and 3 and had the potential to affect all the patients served by this facility.

Findings include:

Facility Policy Titled: Medication Administration

I. Purpose: To ensure that medications are transcribed, administered, and documented in a safe and efficient manner.

III. Policy

B... LPNs (Licensed Practical Nurse) who have been trained in IV therapy may administer premixed IV fluids.

C... Any medication added to IV fluids will be labeled with name of drug, amount of drug, date & time of preparation, initials of RN (Registered Nurse) preparing mixture, patient name and location.

Delmar Nurse's Drug Handbook/Drug Administration
Section 5: Nursing Consideration for Nursing Process: Implementation of the Administration of Medications by Different Routes.

Tablets/Capsules
1. Unless a tablet is scored, it should never be broken to adjust dosage. Breaking can cause incorrect dosage, gastrointestinal (GI) irritation, or destruction of the drug in an incompatible pH. If indicated, scored tablets can be split with a pill splitter or file. Always wear gloves, pick up the tablet and place it in the pill cutter, cut it in half, and either save the other half for the next dose or dispose of according to facility policy.

1. An observation was conducted with Employee Identifier (EI) # 2, the Registered Nurse (RN) on 8/30/11 at 8:20 to observe medication administration for 3 patients.

EI # 2 was to administer Imdur 15 mg (milligrams) to Patient Identifier (PI) # 6. EI # 2 obtained an Imdur 30 mg tablet and a pill cutter and entered PI # 6 's room at 8:20 AM. EI # 2 placed an unscored Imdur 30 mg tablet in the pill cutter with bare hands, cut the tablet and administered the 1/2 tablet to the patient. EI # 2 placed the pill cutter in her/his pocket and went to obtain the next patient's medication.

EI # 2 entered PI # 2's room to administer medications. PI # 2 was to received Lisinopril 2.5 mg. EI # 2 obtained an unscored Lisinopril 10 mg tablet from the medication system. EI # 2, without gloves on, placed the Lisinopril 10 mg tablet in the same pill cutter used for PI # 6 (which had not been cleaned and still contained medication powder on it) and cut the unscored tablet in half. EI # 2 then placed 1/2 of the Lisinopril tablet in the pill cutter and cut the 1/2 tablet into 1/4 and gave the patient 1/4 of the unscored Lisinopril 10 mg tablet.

EI # 2 then obtained the medication of PI # 5 from the medication system. PI # 5 was to receive Nadolol 20 mg. EI # 2 obtained an unscored Nadolol 40 mg tablet. EI # 2 entered PI # 5's room at 8:50 AM an placed the Nadolol in the same pill cutter used for PI #s 6 and 2 (which still contained powder from both patients' cut medication) and placed the unscored Nadolol in the pill cutter with ungloved hands. EI # 2 then administered the 1/2 Nadolol tablet.

EI # 2 failed to notify the Pharmacist of the unavailability of the above medications for the right dose, cut unscored medications, and failed to wear gloves and clean the pill cutter between patients.

2. An observation was conducted with EI # 4, the LPN on 8/30/11 at 9:20 AM to observe medication administration for PI # 3. EI # 4 mixed Clindamycin 600 mg in a 100 cc (cubic centimeter) bag of normal saline. EI # 4 took the medication in to PI # 3's room and realized PI # 3 had a central line and stated," I can not administer medication to a central line and have to get EI # 3, the Charge Nurse to give this to the patient." EI # 4 went to EI # 3 and told her/him of the need for an Registered Nurse to administer the IV Clindamycin. EI # 3 went into PI # 3's room and administered the IV medication without verifying it was Clindamycin.

An interview with the EI # 10, the Director of the Pharmacy was conducted on 8/31/11 at 8:00 AM. The surveyor asked what should the nurse have done with the unscored tablets. EI # 10 stated EI # 2 should have called the pharmacy. The surveyor then asked if EI # 4 (LPN) should have mixed the Clindamycin and should EI # 3 (Charge Nurse) have verified the IV medication administered was Clindamycin and the response was, "yes".