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Based on observations, review of documents, medical records and interviews, it was determined the Governing Body failed to carry out the functions required for the governing body as evidenced by failure to document approval dates for policies, ensure the Certified Registered Nurse Practitioner was directly supervised by a member of the medical staff with a collaborative practice agreement, develop an Emergency Preparedness Program, and ensure the physical environment met all regulations.

Findings:

Refer to A-0043, A-0045, A-0392, A-0620, A-0630, E-0001, E-0004, E-0013, E-0015, and E-0029.

Based on observations and interviews during a facility tour with facility staff and the Life Safety Code surveyor, it was determined the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to affect all patients served by this facility.

Finding include:

Refer to Tags K-0324, K-0345, and K-0511.

The facility failed to establish the Emergency Preparedness Program to meet the Condition of Participation 482.15 Emergency Preparedness.

Findings include:

Refer to tags E 0004, E 0013, E 0015 and E0029.

Based on review of credentialing files, Board of Directors (BOD) meeting minutes, Alabama Board of Medical Examiners Administrative Code and interview, it was determined the facility failed to ensure the nurse practitioner was directly supervised by a member of the medical staff with a collaborative practice agreement for supervision.

Findings include:

Alabama Board Of Medical Examiners Administrative Code
Chapter 540-X-8
Advanced Practice Nurses: Collaborative Practice

540-X-8-.08 Requirements For Collaborative Practice By Physicians And Certified Registered Nurse Practitioners.

(1) The collaborating physician shall:

(a) Provide professional medical oversight and direction to the certified registered nurse practitioner.
..(d) Be readily available at each remote practice site.

1. Review of the 5/10/23 BOD Meeting Minutes "New Business" notation revealed the facility's psychiatrist, also serving as Medical Director, was currently the sole member of the medical staff.

Review of the Medical Director's credentialing file revealed he/she had no collaborative practice agreement with the CRNP.

Review of the CRNP credentialing file revealed he/she had a Collaborative Practice Agreement with a physician who was not a member of the medical staff for the facility.

In an interview conducted 3/6/24 at 3:15 PM with Employee Identifier (EI) # 2, Chief Nursing Officer, EI # 2 confirmed the Medical Director did not have a collaborative agreement with the CRNP.

Based on review of Medical Records (MR), facility policy and procedure, and interviews with staff it was determined the facility failed to ensure a reassessment of the patient's pain level was documented after an as needed (PRN) pain medication was administered.

This affected three of seven MR's reviewed that received PRN pain medications including Patient Identifier (PI) # 2, PI # 4, and PI # 7, and had the potential to negatively affect all patients who received PRN pain medications in the facility.

Findings include:

Facility Policy: Pain Assessment, Reassessment and Management
Policy Number: BH1031
Approved Date: None

Purpose:

- To provide guidance on safely providing patients with an acceptable level of comfort.

- Effective pain assessment and management can remove the adverse psychological and physiological effects of unrelieved pain. Optimal management of the patient experiencing pain enhances healing and promotes both physical and psychological wellness.

Policy:

Creekside Hospital shall respect and support the patient's right to optimal pain assessment and management.

- Patient's have the right to pain management through assessment, intervention, and reassessment.

Procedure:

It shall be the responsibility of clinical staff to:

- Perform an appropriate assessment and reassessment of the patient's pain...

...Reassessment of Pain:

...Any patient care provider from any department who has implemented a pain control mechanism shall reassess the patient within one (1) hour to determine amount of pain control or relief achieved.

...Documentation:

- Pain assessments and reassessments
- Response to pain medications...

1. PI # 2 was admitted to the facility on 2/27/24 with diagnoses including Schizophrenia and Essential Primary Hypertension.

Review of PI # 2's Doctor's Orders revealed the following medication orders:

2/27/24 1:15 PM - Hydrocodone-Acetaminophen, 7.5-325 mg (milligrams) x (times) one tablet, oral tablet, four times a day PRN for pain.

2/27/24 11:30 PM -Tylenol, 325 mg x two tablets, oral tablet, every four hours PRN back pain.

3/1/24 2:05 PM - Methocarbamol 500 mg x one tablet, oral tablet, two times a day PRN muscle relaxer.

Review of PI # 2's Med Log for dates 2/27/24 to 3/5/24 revealed the following medications were administered for pain by the Registered Nurse (RN) with no documentation of a pain reassessment within one hour to determine the amount of pain control or relief achieved:

2/27/24 11:48 PM - Tylenol 325 mg, two tablets oral.

2/28/24 8:33 PM - Tylenol 325 mg, one tablet, oral.

2/29/24 3:50 AM - Tylenol 325 mg two tablets, oral.

2/29/24 8:44 PM - Tylenol 325 mg two tablets, oral.

3/1/24 8:18 AM - Tylenol 325 mg two tablets, oral.

3/1/24 2:06 PM - Methocarbamol 500 mg tablet, oral.

3/1/24 6:37 PM - Hydrocodone-Acetaminophen 7.5-325 mg, one tablet, oral.

3/1/24 9:40 PM - Tylenol 325 mg two tablets, oral.

3/2/24 3:05 AM - Tylenol 325 mg two tablets, oral.

3/2/24 9:00 AM - Methocarbamol 500 mg tablet, oral.

3/2/24 9:11 AM - Tylenol 325 mg two tablets, oral.

3/3/24 7:56 AM - Methocarbamol 500 mg tablet, oral.

3/3/24 2:17 PM - Hydrocodone-Acetaminophen 7.5-3 mg, one tablet, oral.

3/3/24 8:00 PM - Hydrocodone-Acetaminophen 7.5-325 mg, one tablet, oral.

3/4/24 7:56 AM - Methocarbamol 500 mg tablet, oral.

3/4/24 8:37 PM - Methocarbamol 500 mg tablet, oral.

3/5/24 8:31 AM - Methocarbamol 500 mg tablet, oral.

3/5/24 8:31 AM - Tylenol 325 mg two tablets, oral.

3/5/24 2:22 PM - Hydrocodone-Acetaminophen 7.5-325 mg, one tablet, oral.

3/5/24 8:44 PM - Hydrocodone-Acetaminophen 7.5-325 mg, one tablet, oral.

The facility RN's failed to reassess PI # 2's level of pain relief within one hour of administering PRN pain medications per policy.

In an interview conducted on 3/6/24 at 5:47 PM with Employee Identifier (EI) # 2, Chief Nursing Officer, EI # 2 confirmed there was no documentation of a pain reassessment per facility policy after the pain medications were administered.


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2. PI # 4 was admitted to the facility on 2/9/24 with diagnoses including Major Repressive Disorder and Alcohol Use Disorder.

Review of PI # 4's Doctor's Orders revealed the following medication orders:

Methocarbamol, 500 mg x one tablet, two x a day PRN muscle relaxer.

Review of PI # 4's Med Log for dates 2/9/24 to 2/16/24 revealed the following medications were administered for pain by the RN with no documentation of a pain reassessment within one hour to determine the amount of pain control or relief achieved:

2/11/24 8:37 AM - Methocarbamol 500 mg tablet, oral.

2/12/24 7:39 AM - Methocarbamol 500 mg tablet, oral.

2/13/24 8:20 AM - Methocarbamol 500 mg tablet, oral.

2/14/24 8:14 AM - Methocarbamol 500 mg tablet, oral.

2/14/24 8:51 PM - Methocarbamol 500 mg tablet, oral.

2/15/24 8:53 PM - Methocarbamol 500 mg tablet, oral.

2/16/24 8:56 AM - Methocarbamol 500 mg tablet, oral

An interview was conducted on 3/6/24 at 5:55 PM with EI # 2 who confirmed there was no documentation of a pain reassessment per facility policy after the pain medications were administered.

3. PI # 7 was admitted to the facility on 2/25/24 with diagnoses including Schizophrenia and Psychotic Disorder with Delusions.

Review of PI # 7's Doctor's Orders revealed the following medication orders.

Ibuprofen, 200 mg x 2 tablets, oral every six hours PRN for pain.

Review of PI # 7's Med Log for dates 2/25/24 to 3/1/24 revealed the following medication was administered for pain by the RN with no documentation of a pain reassessment within one hour to determine the amount of pain control or relief achieved:

2/28/24 8:05 AM - Ibuprofen 200 mg x 2 tablets, oral.

In an interview conducted on 3/6/24 at 5:50 PM with EI # 2, who confirmed there was no documentation of a pain reassessment per facility policy after the pain medication was administered.

Based on observations, review of facility policies and procedures, manufacturer's directions for use (DFU) for Sanitizer E. S. (Effective Sanitizer) and interviews with staff it was determined the facility failed to ensure:

1. Safe storage of food items in the dietary department.

2. Foods were labeled with the open date.

3. Sanitizing solutions were mixed per the manufacturer's DFU and tested for proper concentration of chlorine with results documented.

This had the potential to affect all patients admitted to this hospital.

Findings include:

Facility Policy: Food and Nutrition Services
Policy Number: BH1145
Approved Date: None

Policy:

Nutrition Services shall be responsible for storing, preparing, and distributing food and nutrition supplies in the proper area(s).

Facility Policy: Nutritional Services Safety
Policy Number: BHEC1306
Approved Date: None

Policy:

The Nutritional Services Director ... shall prepare a cleaning schedule and sanitation checklist. He/she shall be responsible for the schedule being followed in a satisfactory manner.

Procedures for washing, rinsing, and sanitizing pots, pans and utensils shall be developed, posted, and followed.

Sanitizer E.S. Technical Data Sheet
Product Directions
Equipment To Use
Jug or pail pump, wall pump or faucet feeder, recommended automatic dispensing system.

Directions To Use

Utensil Sanitation:

Pre-flush utensils and glasses whenever possible. Wash in first sink using recommended detergent. Rinse in second tank. Sanitize in two ounces to five-gallon solution 200 parts per million (ppm). Immerse all utensils for at least 2 minutes or for contact time specified by governing sanitary code ...

1. A tour of the dietary department was conducted on 3/5/24 at 11:49 AM with Employee Identifier (EI) # 3, Dietary Manager, which included observations in the following areas:

a. Dry storage:
One bag of Pioneer Old Fashioned Biscuit Gravy Mix, opened, being stored inside an open cardboard box without an open date.

b. Walk-in refrigerator:
One gallon of vitamin D whole milk, opened with no open date.
One (1) 9-ounce pack of Land O Frost honey ham, opened in a zip lock bag with no open date.

c. Observation of Fresh Brewed Iced Tea dispensers:
one (1) sweet, one (1) unsweet revealed no prepared or expiration dates.

An observation of the three compartment sink conducted on 3/5/24 at 12:10 PM revealed all three sinks were filled with water. EI # 3 proceeded to add an unmeasured amount of sanitizer E. S. Liquid Sodium Hypochlorite to the third sink. EI # 3 stated the water had to be 180 degrees to sanitize and testing is done three times a day but had not started documenting test results due to not having a form to document on. When asked what is used to test the sanitizer, EI # 3 left the room and returned with chlorine test strips and tested the sanitizing solution with a test strip. The surveyor requested the chlorine testing log. EI # 3 explained that she did not have a log made to record test results.

The dietary manager failed to ensure staff labeled foods with an opened date, a prepared and discard date, and failed to ensure staff were testing for correct concentration of sanitizer and documenting the results.

An interview was conducted on 3/5/24 at 12:30 PM with EI # 3 who confirmed foods were not stored and labeled appropriately, and there was no documentation of testing of sanitizing solution for appropriate concentration per manufacturer's DFU.

Based on review of medical records (MR), and interview, it was determined the facility failed to obtain a physician order for a change to a puree diet.

This deficient practice affected one of seven MR's reviewed, and did affect Patient Identifier (PI) # 1, and had the potential to negatively affect all patients admitted to this facility.

Findings include:

1. During an observation of plating on 3/5/24 at 12:30 PM with Employee Identifier (EI) # 3, Dietary Manager, the surveyor observed pureed food plated for PI # 1.

The surveyor requested the diet order, and EI # 3 provided a hand written dietary communication slip for the pureed diet.

Review of the MR for PI # 1 revealed a physician order dated 2/26/24 for a mechanical soft diet.

Further review of the MR revealed there was no physician order for a pureed diet.

The facility failed to obtain a new diet order from the physician for a pureed diet.

An interview was conducted on 3/6/24 at 1:10 PM with EI # 4, Registered Nurse (RN), who confirmed there was no documentation of a physician order to change the diet from mechanical soft to puree in the medical records.

Based on review of the Emergency Preparedness (EP) Plan and interviews with staff, it was determined the facility failed to document the EP plan was reviewed and accepted by the Governing Body (GB). This had the potential to affect all persons served by this facility.

Findings include:

A review of the EP Plan revealed no individualized plan for the facility based on a facility/community-based risk assessment, communication plan utilizing an all-hazards approach, and no date of implementation for the plan.

A review of the GB Meeting Minutes dated 7/20/22 through 1/31/24 revealed no documentation an EP plan was developed and approved by the GB.

An interview conducted on 3/6/23 at 1:30 PM with EI # 1, confirmed the facility failed to develop and approve through the GB, an individualized EP Plan based on the facility's community-based risk assessment and community plan utilizing an all hazards approach.

Based on review of documents provided for the Emergency Preparedness (EP) program, policies and procedures, and staff interviews, it was determined the facility failed to ensure policies and procedures were developed and individualized for the facility. This had the potential to affect all patients, staff and visitors to the hospital.

Findings include:

Review of the EP documents printed for the surveyor revealed no individualized and approved policies and procedures developed for the facility including no facility name, no effective dates and no approval by the Governing Body.

Further review of the documents provided revealed no documentation of a facility-based or community-based all hazards risk assessment and no documentation to include Emerging Infectious Diseases.

An interview conducted on 3/6/24 at 1:55 PM with Employee Identifier (EI) # 1, CEO (Chief Operating Officer), confirmed there were no EP policies and procedures individualized and approved by the Govering Body for the facility.

Based on review of the Emergency Preparedness (EP) Plan, observation and staff interview, the facility failed to ensure a plan was developed based on a risk assessment of the facility to include sheltering in place or evacuation. This had the potential to affect all patients, staff and visitors to the facility.

Findings include:

A review of the EP Plan revealed no individualized and approved plan to shelter in place or evacuate.

A tour of the dietary department was conducted on 3/6/24 at 1:55 PM with Employee Identifier (EI) # 1 CEO (Chief Operating Officer) to observe food supplies available to shelter in place. EI # 1 stated his/her goal was to have a ten day supply available to shelter in place if needed.

Review of the food storage available during the observation revealed three large canisters of Quaker Oats on the dietary shelf along with one pack of bread buns and one bag of frozen chicken observed in the freezer.

There was inadequate food available for a ten day supply to shelter in place.

An interview was conducted with EI # 1 during the tour of the dietary department who confirmed the current food supply would not provide adequate subsistence to shelter in place for patients, staff and visitors for ten days and a better plan might be to shelter in place for three days or evacuate. EI # 1 confirmed there was no approved plan developed and no approved policy.

Based on review of the facility's plan for Emergency Preparedness (EP) and staff interviews it was determined the facility failed to ensure a comprehensive communication plan was documented for the EP Program. This had the potential to affect all patients, staff and visitors.

Findings include:

A review of the facility EP Plan revealed no documentation of a comprehensive communication plan in case of emergency. The emergency call tree provided to the surveyor included the CEO (Chief Operating Officer), CNO (Chief Nursing Officer) and Director of Maintenance contact information. There was no documentation to include staff and emergency management contact information to coordinate care of the patients and no alternative plan for communication if needed.

An interview was conducted on 3/6/23 at 1:30 PM with Employee Identifier (EI) # 1, CEO, who confirmed there was no documentation of a comprehensive communication plan for the facility.