HospitalInspections.org

Based on observations during a 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 medical records and interview it was determined the nursing staff failed to:

1. Provide ordered wound care and assess wounds in 2 of 2 discharge records reviewed.

2. Document the patient's theraputic diet accurately on the daily nurse note on 2 open records.

3. Follow physician orders for treatment of chest pain.

This had the potential to affect all patients served by the facility and did affect Medical Record (MR) # 23276, # 310971, # 308532 and # 309501.


Findings include:

1. MR # 308532 was admitted to the hospital 4/26/12 with diagnoses of Diabetes Mellitus, Coronary Artery Disease, Nausea and Vomiting and Constipation.

The skin assessment form dated 4/29/12 documented a skin tear 1 cm x 5 cm x 3 cm to the right lower extremity (RLE).

A review of the physician's orders from 4/26/12 through discharge 5/2/12 revealed no wound care orders.

A review of the nurses notes on discharge dated 5/2/12 at 7:15 AM documented, " Dressing noted to RLE dry and intact..."

There was no other documentation in the record to indicate if the skin tear was dressed 4/29/12 after it was identified, if the physician was notified of the skin tear and no orders for any type of dressing to be applied.

In an interview with Employee Identifier(EI) #1, the Quality Assurance nurse on 6/27/12 at 12:30 PM, it was confirmed there was no order for the dressing and no documentation of when it was applied.

2. MR # 309501 was admitted to the hospital 5/20/12 with diagnoses of Seizure disorder, Decubitus and Paraplegia.

The skin assessment form completed by the nurse 5/20/12 documented a fistual 5 1/2 cm x 3 cm x 3 1/2 cm at the coccyx area, a fistula to the left buttock 5 cm x 4 cm x 3 cm, a fistula to the right buttock 5 1/2 cm x 3 cm x 3 cm and a stage II round 2 cm area right hip and a stage II 2 cm x 1 cm to left hip and a burn area to right anterior thigh 3 cm x 1/2 cm.

A physician's order was present for 5/20/12 per home regimen, " Clean decubitus wounds with sterile water, apply 4 x 4's and tape every day."

There was no mention of the fistulas or the burn to the right anterior thigh and no documentation if these areas were dressed while the patient was in the hospital.

The patient was discharged home with the same areas identified on the skin assessment form however not labeled as decubitus or fistulas.

In an interview with Employee Identifier(EI) #1, the Quality Assurance nurse on 6/27/12 at 12:30 PM, it was confirmed there was no order for dressings to the fistulas or the burn and no documentation of whether it was dressed during the hospital stay.



30952

3. MR # 310971 was admitted to the hospital 6/26/12 with diagnoses of Congestive Heart Failure, Hyperkalemia, Dehydration, Bilateral Foot Infections, Chronic Kidney Disease, Hypertension and Anemia.

Review of the Physician's Order Form dated 6/26/12 at 11:42 AM revealed the diet ordered was 1800 Cal (calorie) ADA (American Dietetic Association) , 1000 gram Sodium, and Protein Supplements BID (twice daily).

Review of the Nurse notes dated 6/26/12 to 6/27/12 revealed the patient's diet was documented as 1800 cal ADA, 1000 NA (sodium). A review of the patient's Medication Record also failed to reveal the order for Protein Supplements BID.

An interview was conducted on 6/27/12 at 12:15 PM, with EI # 1 , who validated the documentation on the 6/26/27- 6/27/12 nurse notes and medication records failed to include the patient's correct diet.


4 . MR # 23276 was admitted to the hospital 6/26/12 with diagnoses of Chest Pain, Congestive Heart Failure and Status Post Coronary Artery Bypass Grafts.

Review of the Physician's Order Form dated 6/26/12 at 15:45 PM revealed the patient's diet order was 2 Gram Sodium, Low Cholesterol with 2000 milliliter (ml) fluid restriction and orders for Chest Pain: NTG (nitroglycerin) 1/150 gr (grain) Sublingual Q (every 5 minutes) x 3; Hold if B/P (blood pressure) less that 90 systolic), if no relief, STAT 12 Lead EKG (electrocardiogram), MS (Morphine Sulfate) 2-10 mg (milligrams) in 2 mg increments Q 1-2 hrs (hours) and notify MD (Medical Doctor).

Review of the Nurse note dated 6/26/12 to 6/27/12 revealed the patient's diet was documented as 2 Gram Sodium, Low Cholesterol. A review of the patient's Medication Record also failed to reveal the order for the 2000 ml/fluid restriction.

Review of the Nursing Note dated 6/26/12 at 2000 revealed documentation the patient "c/o chest pain, given nitro 0.4 mg SL (sublingual)...Will continue to monitor".

The next nursing note entry was documented on 6/26/12 at 2030 and revealed the patient " continues to c/o chest pain, given Morphine 2 mg IVP (intravenous push) by the RN ".

The LPN documented on 6/27/12 at 0405 LE (late entry) "c/o pain, given Lortab 5 mg po."

An interview was conducted on 6/27/12 at 12:20 PM with EI # 1, who confirmed the nurse note dated 6/26/12 to 6/27/12 and the patient's Medication list failed to include documentation of the 2000 ml fluid restriction. EI # 1 validated the LPN failed to follow the physician's order for management of chest pain as the LPN failed to administer the NTG as ordered and obtain a STAT EKG when the chest pain was unrelieved.
The LPN documentation was unclear as to the origin of pain that required the Lortab administration.

Based on a review of the pharmacy policy and procedure manual and interview it was determined the facility failed to have reviewed the policies and procedures for provision of pharmacy services. This had the potential to affect the hospital staff and patients.


Findings include:

On 6/27/12 at 7:30 AM, the surveyor reviewed the policy and procedure manual in the pharmacy. The policies had been reviewed and signed and dated for 2012 by the pharmacy technician. There was no indication the Medical Director of the hospital or the pharmacy director had reviewed the policies and procedures. In an interview with Employee Identifier (EI) # 3, the Registered Pharmacist,on 6/27/12 at 7:30 AM it was confirmed the technician had reviewed the policies.

Based on interview and observation it was determined the hospital failed to have an established formulary system approved by the medical staff.


Findings include:

On 6/27/12 at 7:00 AM during an interview with the Employee Identifier(EI) # 3, Registered Pharmacist, he was asked for the hospital formulary. EI # 3 stated that the hospital has an open formulary meaning they will obtain anything a physician orders within reason.

During the exit conference 6/27/12 at 1:55 PM, EI # 2, the Assistant Administrator was asked about about the hospital formulary and replied they have always had an open formulary to encourage physicians to come to the area.

Based on review of the dietary manual and an interview the hospital failed to assure the dietary manual was up to date to meet the needs of the patients and staff and had been approved by the medical staff. This had the potential to affect all consumers served by the dietary department.

Findings include:

Upon entrance to the hospital on 6/26/12 at 8:30 AM the surveyor toured the dietary department.

The surveyor observed the kitchen did not have an automated dishwasher and sanitized the pots and pans in the three compartment sink. The surveyor and the dietary employee looked in the dietary manual for a policy on sanitizing dishes. The policy and procedure manual was last updated 3/30/09.

There was no documentation the medical staff had approved it for use.

In a telephone interview with the Registered Dietitian on 6/26/12 at 11:50 AM, she confirmed the manual needed to be updated.

Based on observation of the dietary department and the facility, it was determine the facility failed to:

1. Ensure the hood vent was clean and in good repair. This had the potential to affect all patients and staff who consume food from this dietary department

2. Remove expired supplies from storage.


Findings include:

On 6/26/12 at 8:40 AM, the surveyor observed the dietary department. During this time, the surveyor observed the hood vent located directly above the stove had multiple layers of dust and grease accumulated located in the interior aspect of the hood vent.

The hood vent was located directly over the stove.

This had the potential to affect everyone served by the hospital.




30952

On 6/27/12 at 10: 00 AM during a tour of the facility, the surveyors toured a small hallway containing a small refrigerator, cabinets, drawers and individual dispenser drawers.

Upon investigation, the surveyors observed the small refrigerator with a 2009 Temperature log taped in the front door, a Styrofoam tray labeled " Quest ", and 3 unopened bottles of Glucose Tolerance Solution. The refrigerator freezer was overcome with excess ice.

Upon opening the cabinets and drawers, the following items were identified:

Two Kendall Xeroflo gauze dressings Overwrap -expiration date 08/2011
One unopened 16/5 Foley Catheter Tray- expiration date 8/2011
One package of Criterion Surgeon's gloves- expiration date 9/2006
One open bottle of Hydrogen Peroxide- dated 10/2/09 (All solutions expire 30 days after opening).
One package of open Xeroform gauze dressing

In the individual dispenser drawers, the surveyors identified an unopened dosage of Lovenox 40 milligram/0.4 milliliters, with an expiration date of 1/2014 and a small white medication cup containing a peach colored pill. The cup was labeled "114".

An interview was conducted with Employee Identifier (EI) # 6, Registered Nurse, on 6/27/12 at 1:00 PM, who reported she/he was unsure why the medications were there, and disposed of the peach pill in the sharps container next to the individual dispenser drawers and returned the Lovenox to the pharmacy.

An interview was conducted with EI # 1, the Quality Assurance nurse and EI # 2, Assistant Administrator, who validated the above.

Based on observation, review of the Centers for Disease Control (CDC) and Prevention best practices, policy review and staff interview, it was determined the facility failed to ensure:
1. The infection control policy for the cleaning of blood glucose meters followed the CDC and Prevention best practices guidelines.
2. Maintain a current policy for the use of the Precision PCX Blood Glucose.
3. Ensure the staff followed its policy for hand hygiene after blood glucose monitoring during 1 of 1 observations of blood glucose monitoring.

Findings include:

Facility Policy RE: 607.55
Revised 1/2001
Title: Hand Washing

Policy:
All employees that have contact with patient's must follow hand-washing techniques to decrease the possibility of nosocomial infections and the spread of infections to other employees.

Procedure:
Hand washing is absolutely essential for the prevention and control of nosocomial infection: there is no substitute for it...
1. Hospital personnel are to wash their hands:
...c. Between care of individual patients.
d. After patient care....
...k. Before preparation and administration of medication...


Facility Policy RE: 607.45
Revised 5/2009
Title: Glucose Testing: Precision G Blood Glucose Testing System

Policy: It is the policy of Georgiana Hospital to provide a consistent procedure for performing and monitoring hospital bedside testing of patient's blood glucose with the Precision B Blood Glucose Testing System.

Procedure:
...6 Place blood on test strip.
7. Place in precision G system as instructed by the manual.
8. Apply cotton ball to patient's digit to stop the bleeding.
...9 Discard of the lancet in appropriate sharps container.
10. Remove gloves and wash hands.
11. Record patient's glucose level on the medication administration record, the patient's chart and on log sheet as indicated.

Quality Control Measure:
...3 Each Precision G machine is timed for these controls to be done at the specific interval. (Refer to Precision G Manual for instructions and values).
...8 The attached manufacturer's procedure guide should be followed.


MediSense
Precision PCX Blood Glucose Testing System
User's Guide
1998 Abbott Lab

Maintenance of the Precision PCX Monitor

The Precision PCX Monitor requires little routine maintenance. During testing, the sample remains outside the monitor, which significantly reduces the possibility of contamination....

Cleaning the Exterior Surface:
Cleaning the Exterior Surface of the Precision PCX Monitor is recommended daily. The monitor needs only to be cleaned with a water-moistened cloth or a sponge and a mild detergent...



Centers for Disease Control and Prevention
January 4, 2012
"Infection Prevention during Blood Glucose Monitoring and Insulin Administration

? FAQs: Blood Glucose Monitoring and Insulin Administration ..........

The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration.

CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements:.....
Fingerstick devices should never be used for more than one person
Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer ' s instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared .... "

1. On 6/27/12 at 11:05 AM the surveyor observed Employee Identifier (EI) # 4, Licensed Practical Nurse, check the blood glucose of Medical Record 310971 with the Precision PCX Blood Glucose test meter (blood glucose monitoring machine). EI # 4 removed his/her gloves after checking the patient's blood glucose, but failed to wash his/her hands per policy before he/she documented the blood glucose results in the patient's chart. EI # 4 then entered the medication room, opened the refrigerator and removed a bottle of Humulin R (Regular). EI #4 donned a clean pair of gloves, prepared the insulin and replaced the Humulin R insulin into the refrigerator. Prior to insulin administration, EI # 4 removed his/her gloves, performed hand hygiene, donned a clean pair of gloves and administered Humulin R 2 units to the patient. EI # 4 removed his/her gloves and placed the gloves in the trash in the patient's room. EI # 4 returned to to nursing station and performed hand hygiene.

EI # 4 did not clean the Precision PCX Blood Glucose meter according to CDC guidelines prior to replacing the meter to the Precision PCX Blood Glucose storage case after patient use.

An interview was conducted on 6/2712 at 11:20 AM. with EI # 4 , who confirmed the staff does not clean the surface of the Precision PCX Blood Glucose test meter between patient's use.

During an interview conducted on 6/27/12 at 12:15 PM, Employee Identifier(EI) #1, the Quality Assurance nurse, confirmed the staff does not clean the surface of the Precision PCX Blood Glucose meter between patient's use nor does the facility clean according to the Precision PCX Blood Glucose Testing System which instructs the user to clean the exterior surface of the Precision PCX Blood Glucose Monitor daily with a moistened water-resistant cloth or a sponge and mild detergent. EI #1 also validated EI # 4 failed to perform hand hygiene according to facility policy.

2. On 6/27/12 ,the surveyor identified the facility policy for the Glucose Testing: Precision G Blood Glucose Testing System RE: 607.45, revised 5/2009. An interview was conducted on 6/27/12 at 11:50 AM, with the EI # 5, Laboratory Manager, regarding the quality control procedures and cleaning of the Precision PCX Blood Glucose meter observed in use on the nursing unit. The surveyor asked EI # 5 for the policy for the use of the Precision PCX Blood Glucose meter. EI # 5 reported the facility did not have a policy for the Precision PCX Blood Glucose meter.

An interview was conducted on 6/27/12 at 12:20 PM with EI # 1, who validated the facility does not have a policy for the Precision PCX Blood Glucose meter, currently being used in the facility.

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