HospitalInspections.org

Based on review of medical records (MR), policies and procedures, and interview with staff, it was determined the facility failed to ensure staff obtained informed consent for a radiological procedure on a pregnant patient. This affected Patient Identifier (PI) # 10, in one of one MR who required a computerized tomography (CT) with contrast (substance used to enhance the visibility of internal structures on X-ray or other imaging scans) and had the potential to negatively affect all patients who require a radiological procedure.

Findings include:

Hospital Radiology Policy and Procedure: Consent for Contrast

Review Date: 3/7/24

Policy: The Radiology Department determines those radiological procedures where evidence of consent should be documented. These... require...a consent form signed by the patient or other responsible party...prior to the examination.

Procedure:

1. A consent form is completed and signed by the patient for the following:

a. IV (intravenous) contrast exams
b. Pregnancy Acknowledgement

2. The patient presents to the Radiology Department for their radiographic examination...provided with a consent form...asked to sign the consent form in the presence of...technologist...

Hospital Radiology Policies and Procedure: Pregnant Patient
Review Date: 3/7/24

Policy:

If a pregnant patient arrives in the Radiology Department for an exam or a patient is determine(d) to be pregnant...the case must be discussed with the radiologist and the patient's physician prior to administering any radiation procedure. If both physicians determine the exam is medically necessary, the patient will be provided with the pregnancy consent to sign acknowledging the risk and necessity.

Procedure:

1. When the patient has been determined to be pregnant...attending physician and radiologist are in agreement...observe the following steps:

a. The radiologist will give the technologist specific instructions for performing the procedure...may include limitations on number of images and positions.
b. The radiologist may monitor the procedure if necessary.
c. The procedure should be discussed with the patient and any questions...addressed at that time.
d. The patient and the witnessing technologist should sign the pregnancy consent form as acknowledgement.

...2. The technologist...responsible for scanning in the Pregnancy Consent Form into the patient's MR for documentation.

1. PI # 10 was admitted to the facility on 5/11/25, with a chief complaint of a fall.

Record review revealed a CT of the abdomen/pelvis with IV contrast was performed 5/11/25 at 2:40 PM.

Further review of the record revealed urine pregnancy test results dated 5/11/25 at 2: 43 PM were positive.

There was no documentation staff inquired about the possibility of pregnancy. There was no documentation PI # 10 was informed about the potential risk of the radiological procedure, CT with IV contrast, no documentation the radiology department obtained a consent for CT with IV contrast, and no pregnancy acknowledgment.

An interview was conducted on 5/22/25 at 1:19 PM with Employee Identifier # 2, Chief Nursing Officer, who confirmed there was no documentation PI # 10 was informed about the radiation risk to an unborn baby, the benefits of the CT scan with IV contrast, and alternative diagnostic options available. There was no signed consent for radiographic procedures in pregnant patients, and no signed consent for the IV contrast use.






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Based on hospital policy and procedure, observation, and staff interview, it was determined the facility failed to ensure all medications available for patient use, including emergency medications were not expired.

This deficient practice had the potential to affect all patients served by this facility.

Policy: Emergency Drugs-Crash Carts

Policy Number: None

Effective Date: 1/2024

Policy: Emergency drugs and supplies, for use in medical emergencies only, shall be immediately available at each patient care unit or service area. Emergency drugs for resuscitation shall be located in the emergency crash carts.

Procedure: ...3. The emergency drug supply will remain inside the cart, sealed, at all times when not in use...the contents shall be listed in a log on top of the cart and shall include the earliest expiration date of any drugs within the tray.

1. A tour was conducted of the hospital's Emergency Department (ED) on 5/20/25 at 10:00 AM with Employee Identifier (EI) # 1, Chief Executive Officer.

During the tour four single dose vials (SDV) of Dexamethasone Sodium 4 milligram (mg)/milliliter (mL), expired 10/24, and three SDVs Furosemide 40 mg, expired 8/1/24, were observed in the Intubation Box, located in the ED nurses station.

An interview was conducted on 5/20/25 at 11:00 AM with EI # 1, who confirmed staff failed to ensure expired medications were not available for use in the ED.

2. A tour of the facility was conducted on 5/20/25 at 10:20 AM with EI # 2, Chief Nursing Officer (CNO).

During the tour five vials of Norepinephrine Bitartrate injection 4mg/4ml, expired 3/25, were observed in the ED crash cart.

An interview was conducted on 5/20/25 at 10:41 AM with EI # 2, who confirmed staff failed to ensure expired medications were not available for use in the ED.



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Based on review of medical records (MR), hospital policies, and staff interview, it was determined the hospital failed to ensure:

1. Blood transfusions were administered in accordance with medical staff policy and procedure. This affected Patient Identifier (PI) # 1, in one of two outpatient blood transfusions, and had the potential to negatively affect all patients who require a blood transfusion.

2. Staff administered medications as ordered. This affected PI # 9, in one of seventeen Emergency Department (ED) records reviewed, and had the potential to negatively affect all patients treated in the ED.

Findings include:


Policy: Blood-Blood Components-Transfusion-Packed Cells

Policy Number: None

Effective Date: 1/2024

Purpose: Packed cells are transfused when such depressed levels accompany normal blood volume to avoid possible fluid and circulatory overload. Packed cells contain cellular debris, necessitating in-line filtration during administration.

Policy: It is the policy of Bullock County Rural Emergency Hospital to provide a safe and uniform method of administration of packed cells.

Procedure: ...If the patient does not have an intravenous (IV) line in place, perform venipuncture, using at least a 20 gauge catheter or needle. Do not use an existing line if the needle or catheter lumen is smaller than a 20 gauge (preferred gauge is 18).

1. PI # 1 was admitted to outpatient services on 3/12/25 with a diagnosis of Anemia.

Review of the 3/12/25 Outpatient Nurse Note revealed no documentation a venipuncture was performed and the gauge of the catheter or needle.

An interview was conducted on 5/22/25 at 1:32 PM with Employee Identifier # 2, Chief Nursing Officer who confirmed there was no documentation a venipuncture was performed and the gauge of the catheter or needle.



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2. PI # 9 was admitted to the ED on 4/11/25 with a chief complaint of chest discomfort.

Review of the physician orders revealed an order dated 4/11/25 for Lasix 10 milligram (mg) IV, give now.

Review of the MR revealed no documentation staff administered Lasix 10 mg IV.

An interview was conducted on 5/22/25 at 1:12 PM with EI # 2, who confirmed there was no documentation Lasix 10 mg IV was administered as ordered.

Based on review of medical record (MR)s, hospital policies, and staff interviews, it was determined the facility failed to identify and report all occurrences/events. These failures prevented the facility the ability to investigate and implement corrective actions to prevent future occurrences and errors.

This affected Patient Identifier (PI) # 10, and PI # 9, in two of twenty MR reviews and had the potential to negatively affect all patients treated at the hospital.

Findings include:

Hospital Policy and Procedure: Incident Reports and Risk Occurrences
Effective Date: 1/24

Policy:

...Incidents and occurrences...include... anything that results in an injury or has potential for injury.
All patients...will be provided with an environment...free if incident hazards as possible...

An incident report shall include but not limited to:
...3. Errors of Omissions...
4. Inappropriate treatments, tests...
5. Any event, incident or accident, which results in an injury or has potential for injury, a medication error or omission...

Emergency Department (ED) Policy: Medication Errors
Effective Date: 1/2024

Policy:

The organization has a process to respond to actual or potential medication errors. All significant medication error reports will be reviewed by Pharmacy and Therapeutics (P & T) Committee ...
When a medication error occurs, the following should occur ...
Notify the physician ...
Report the error in detail ...on a Risk Occurrence Form.
...forward the Medication Error Form to the ...nursing administrator or Director of Pharmacy.
All medication error reports will be reviewed by the P&T Committee ...

1. PI # 10 was admitted to the facility on 5/11/25, with a chief complaint of fall.

Record review revealed computed tomography (CT) of the abdomen/pelvis with intravenous (IV) contrast was performed 5/11/25 at 2:40 PM.

Further record review revealed PI # 10's urine pregnancy test results dated 5/11/25 at 2:43 PM were positive.

Review of the MR revealed no documentation the staff inquired about the possibility of pregnancy. There was no documentation PI # 10 was informed about the potential risk of the radiological procedure, CT with IV contrast, no documentation the radiology department obtained a consent for CT with IV contrast, and no pregnancy acknowledgment.

An interview was conducted on 5/22/25 at 1:19 PM with Employee Identifier (EI) # 2, Chief Nursing Officer, who confirmed there was no documentation an occurrence report was completed per the facility policy.

2. PI # 9 was admitted to the ED on 4/11/25 with a chief complaint of chest discomfort.

Review of a physician order dated 4/11/25 revealed Lasix 10 milligram (mg) IV give now.

Review of the MR dated 4/11/25 revealed no documentation the Lasix 10 mg IV was administered per the physician order.

An interview was conducted on 5/22/25 at 1:12 PM with EI # 2, who confirmed staff failed to administer IV Lasix, and no medication error report had been completed.

Based on observation, the Hydrocollator Heating Unit maintenance recommendations, and staff interviews, it was determined the facility failed to ensure:

1. Staff followed the maintenance and cleaning recommendations for the Chattanooga Hydrocollator. This had the potential to negatively affect patients who required Hot Pac (application of heat to an area of the body to relieve pain and stiffness, and promote healing) treatments.

2. Intravenous (IV) start was performed according to hospital policy.

This affected an unsampled patient, in one of one peripheral IV starts observed, and had the potential to negatively affect all patients who require an IV at the facility.

Findings include:

Hydrocollator Heating Units Service/User Manual
Chattanooga Group

...Maintenance

The Hydrocollator Heating Unit is equipped with an immersion type heating element .... which ...maintains the Hot Pac temperature in the water and provides a ready supply of heated packs ...The tank should ...be drained and cleaned systematically at minimum intervals of every two weeks ...

Cleaning Tips

1. The interior of the unit should be cleaned, at least every two weeks...

Policy and Procedure: IV Therapy - Starting Peripheral IV Line

Policy Number: None

Effective Date: 1/2024

Procedure: ....11. Cleanse the venipuncture site with a Chlora prep stick for two to three (2-3) minutes...

1. A tour of the outpatient Physical Therapy department was conducted on 5/20/25 at 11:37 AM.

The surveyor observed a Chattanooga Hydrocollator Heating Unit in the patient treatment area.

An interview was conducted on 5/20/25 at 2:45 AM with Employee Identifier (EI) # 8, Licensed Physical Therapy Assistant. The surveyor asked EI # 8 how often the hydrocollator is used and when the hydrocollator was last cleaned. EI # 8 reported the hydrocollator is used daily and is cleaned every four weeks. EI # 8 reported there was no documentation when the hydrocollator was last drained and cleaned.

The facility failed to ensure staff performed and documented draining and cleaning of the hydrocollator heating unit.

An interview was conducted on 5/22/25 at 4:30 PM with EI # 1, Chief Executive Officer, who confirmed there was no documentation the hydrocollator was maintained and cleaned per the manufacturer's recommendations.



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2. An observation was conducted on 5/21/25 at 2:32 PM with EI # 7, Emergency Department Nurse to observe an IV start on an unsampled patient. EI # 7 failed to cleanse the venipuncture site with a Chlora prep stick for two to three minutes prior to insertion of the catheter.

An interview was conducted on 5/22/25 at 1:48 PM with EI # 2, Chief Nursing Officer who confirmed staff failed to cleanse the venipuncture site per facility procedure.

Based on hospital policy, medical record (MR) review, and staff interview, it was determined the hospital failed to ensure the process to identify the need for a discharge evaluation was documented.

This deficient practice did affect seven of seven MR's reviewed, and had the potential to affect all patients requiring observation served by the facility.

Findings include:

Hospital Policy: Discharge Planning - Emergency Department

Policy Number: None Listed

Effective Date: 1/2024

Policy: All patients discharged from the Emergency Department will receive discharge instructions from the Emergency Department nurse.

Review of seven of seven MRs of patients discharged from the Emergency Department revealed no documentation of the process to identify the need for a discharge evaluation.

An interview was conducted on 5/22/25 at 2:07 PM with Employee Identifier (EI) # 2, Chief Nursing Officer who revealed no discharge planning process in place.

Based on hospital policy and procedure, medical record (MR) reviews, and interview, it was determined the facility failed to ensure:

1. Suicide screening assessments were performed and documented on all patients.

This affected eight of seventeen patients admitted to the Emergency Department (ED), and included Patient Identifier (PI) # 16, PI # 8, PI # 13, PI #14, PI # 7, PI # 9, PI # 10, PI # 20. This deficient practice had the potential to affect all patients served by this facility.

2. 1:1 observation of suicidal patient's current observation status was documented.

This affected one of one MR's reviewed of patients admitted to the ED with suicidal ideations and had the potential to affect all suicidal patients served by the facility. This affected PI # 6.

ED Policy Title: Suicide Assessment and Precautions

Review Date: 4/10/23

Policy Purpose: Staff observing potential suicidal statements and behaviors exhibited by patients will report to ER nurse and Physician immediately and take measures to promote safety. Suicide precautions (also known as 1:1 or 1:1 within arms reach) will be initiated when a patient actively demonstrates suicidal ideations or behaviors or when ordered by clinician.

Procedure:

1. Patients are screened for Suicide Risk on the Suicide Risk Assessment area of the Admission Nursing Assessment in the electronic health record or downtime form.

2. Patients are screened for suicidal and homicidal ideations during nursing triage and as indicated on the shift assessment flowchart in the electronic health record or the downtime shift assessment form.

Policy: One to One Observation

Policy Number: O.1

Effective Date: 1/1/24

Policy Purpose: One-to-One supervision is close observation of patients who have been identified as an imminent danger to themselves or others...

Observation: Observation statuses should be documented in the patients progress notes, identifying current observation status.

Findings:

1. PI # 16 was admitted to the ED on 3/29/25 with a chief complaint of left sided weakness.

Review of the MR revealed no suicide risk screening documentation.

An interview was conducted on 5/22/25 at 1: 34 PM with EI # 2, Chief Nursing Officer, who confirmed the staff failed to perform and document the suicidal risk screening.

2. PI # 8 was admitted to the ED on 4/3/25 with a chief complaint of high blood sugar.

Review of the MR revealed no suicide risk screening documentation.

An interview was conducted on 5/22/25 at 1:36 PM with EI # 2 who confirmed the staff failed to perform and document the suicidal risk screening.

3. PI # 13 was admitted to the ED on 1/27/25 with a chief complaint of pregnancy discomfort.

Review of the MR revealed no suicide risk screening documentation.

An interview was conducted on 5/22/25 at 1: 45 PM with EI # 2 who confirmed the staff failed to perform and document the suicidal risk screening.



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4. PI # 14 was admitted to the ED on 2/12/25, and the chief complaint was psychiatric evaluation.

Review of the ED Provider Note documentation dated 2/12/25 revealed PI # 14's active problems included schizophrenia, chronic post-traumatic stress disorder, and aggressive behavior.

Review of the MR revealed no suicide risk and homicidal risk screening documentation.

An interview was conducted on 5/22/25 at 1:23 PM with EI # 2 who confirmed the staff failed to perform and document the suicide and homicide risk screening.

5. PI # 7 was admitted to the ED on 2/19/25, the chief complaint was shortness of breath.

Review of the MR revealed no suicide risk screening documentation.

An interview was conducted on 5/22/25 at 1:08 PM with EI # 2 who confirmed there was no documentation suicide risk screening was conducted.

6. PI # 9 was admitted to the ED on 4/1/25, the chief complaint was chest discomfort.

Review of the MR revealed no suicide risk screening documentation.

An interview was conducted on 5/22/25 at 1:12 PM with EI # 2 who confirmed there was no documentation suicide risk screening was conducted.

7. PI # 10 was admitted to the ED on 5/11/25, the chief complaint was fall.

Review of the MR revealed no suicide risk screening documentation.

An interview was conducted on 5/22/25 at 1:19 PM with EI # 2 who confirmed there was no documentation suicide risk screening was conducted.

8. PI # 20 was admitted to the ED on 2/28/25, the chief complaint was pain to the left side of the face.

Review of the MR revealed no suicide risk screening documentation.

An interview was conducted on 5/22/25 at 1:31 PM with EI # 2 who confirmed there was no documentation suicide risk screening was conducted.

9. PI # 6 was admitted to the facility on 1/18/25 with a chief complaint of mental health.

Review of the MR revealed a physician order dated 1/18/25 at 6:51 PM for 1:1 observation.

Review of the MR revealed no documentation the patient was placed on 1:1 observation.

An interview was conducted on 5/22/25 at 1:42 PM with EI # 2 who confirmed there was no documentation of the 1:1 observation.

Based on review of facility policies and procedures, medical records (MR), and staff interviews, it was determined the facility failed to ensure:

1. Physician orders included the frequency for monitoring patient vital signs. This affected seventeen of seventeen emergency department (ED) and observation record reviews.

2. Physician orders were authenticated within a twenty-eight-day timeframe per hospital policy.

3. Staff conducted and documented transfer team report for all patients transferred from the hospital to a higher level of care.

This affected eleven of seventeen emergency department and observation record review including PI # 20, PI # 15, PI # 9, PI # 14, PI # 2, PI # 5, PI # 7, PI # 9, PI # 4, PI # 6, PI # 8, and had the potential to negatively affect all patients admitted to the facility.

Findings include:

Emergency Department and Observation Policy and Procedure: Vital Signs
Review Date: 6/6/23

Policy:

VS may include...temperature, respirations, pulse, and blood pressure.

...Hospital will establish a detailed process for the reporting of VS results to the nurse and establish the frequency that VS are required. VS frequency should be performed per Physician Order and as needed for changes in patient condition...

Facility Health Information Management Procedure Title: Notification of Deficient-Delinquent Records
Review Date: 3/15/23

Purpose: To ensure timely completion of medical records...

Procedure...monitor and communicate medical record deficiencies...on a weekly basis.

...First notification of delinquency of records:

Physician...notified...has charts 28 days from date of discharge considered delinquent...not completed...

ED Policy and Procedure Title: Transfer of Patient to Another Facility
Review Date: 4/10/23

Policy:
...If transfer is necessary to a higher level of care....

Procedure:

...Transfer papers will be completed...Copy of medical records...will accompany the patient. Documentation shall include, but is not limited to:

Report given to transport team...

1. Review of seventeen of seventeen records MRs revealed no documentation of physician orders with frequency patient vital signs were to be monitored.

An interview was conducted on 5/22/25 at 1:31 PM with Employee Identifier (EI) # 2, Chief Nursing Officer, who confirmed there was no documentation of physician orders for the frequency vital signs were to be monitored.

2. PI # 20 was admitted to the facility on 2/28/25 with a chief complaint of pain left side of (the) face.

Review of the MR revealed four orders dated 2/28/25, "pending" not signed/authenticated by the physician within 28 days of discharge.

An interview was conducted on 5/22/25 at 1:31 PM with EI # 2, who confirmed physician orders were not authenticated per facility procedure.

3. PI # 15 was admitted to the facility on 3/1/25 with a chief complaint of chest pain.

Review of the MR revealed fourteen orders dated 3/1/25, "pending" not signed/authenticated by the physician within 28 days.

An interview was conducted on 5/22/25 at 1:26 PM with EI # 2, who confirmed physician orders were not authenticated per hospital procedure.

4. PI # 9 was admitted to the facility on 4/1/25 with a chief complaint of chest discomfort.

Review of the MR revealed fourteen orders dated 4/1/25, "pending" not signed/authenticated by the physician within 28 days.

An interview was conducted on 5/22/25 at 1:12 PM with EI # 2, who confirmed physician orders were not authenticated per hospital per facility procedure.

5. PI # 14 was admitted to the facility on 2/12/25 with a chief complaint of psychiatric evaluation (for medical clearance).

Review of the MR revealed seven orders dated 2/12/25, "pending" not signed/authenticated by the physician within 28 days.

An interview was conducted on 5/22/25 at 1:23 PM with EI # 2, who confirmed physician orders were not authenticated per hospital procedure.

6. PI # 2 was admitted to the facility on 5/6/25 with a chief complaint of possible stroke.

Review of the record revealed a transfer to a higher level of care occurred on 5/6/25.

The MR failed to include documentation ED staff provided a report to the transport team.

An interview was conducted on 5/22/25 at 12:50 PM with EI # 2 who confirmed there was no documentation the transport team report was provided per hospital policy.

7. PI # 5 was admitted to the facility on 1/14/25 with a chief complaint of flu symptoms.

Review of the record revealed a transfer to a higher level of care occurred on 1/14/25.

The MR failed to include documentation ED staff provided a report to the transport team.

An interview was conducted on 5/22/25 at 1:03 PM with EI # 2 who confirmed there was no documentation the transport team report was provided per hospital policy.

8. PI # 7 was admitted to the facility on 2/19/25 with a chief complaint of shortness of breath.

Review of the record revealed a transfer to a higher level of care occurred on 2/19/25.

The MR failed to include documentation ED staff provided a report to the transport team.

An interview was conducted on 5/22/25 at 1:08 PM with EI # 2 who confirmed there was no documentation the transport team report was provided per hospital policy.

9. PI # 9 was admitted to the facility on 4/11/25 with a chief complaint of chest discomfort.

Review of the record revealed a transfer to a higher level of care occurred on 4/11/25.

The MR failed to include documentation ED staff provided a report to the transport team.

An interview was conducted on 5/22/25 at 1:12 PM with EI # 2 who confirmed there was no documentation the transport team report was provided per hospital policy.




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10. PI # 4 was admitted to the facility on 12/24/24 with a chief complaint of medication overuse.

Review of the MR revealed four orders dated 12/24/24, "pending" not signed/authenticated by the physician within 28 days of discharge.

An interview was conducted on 5/22/25 at 1:40 PM with EI # 2 who confirmed physician orders were not signed/authenticated per facility procedure.

11. PI # 6 was admitted to the facility on 1/8/25 with a chief complaint of mental health.

Review of the MR revealed twenty orders dated 1/18/25, "pending" not signed/authenticated by the physician within 28 days of discharge.

An interview was conducted on 5/22/25 at 1:42 PM with EI # 2 who confirmed physician orders were not signed/authenticated per facility procedure.

12. PI # 8 was admitted to the facility on 4/3/25 with a chief complaint of high blood sugar.

Review of the MR revealed fifteen orders dated 4/3/25, "pending" not signed/authenticated by the physician within 28 days of discharge.

An interview was conducted on 5/22/25 at 1:36 PM with EI # 2 who confirmed physician orders were not signed/authenticated per facility procedure.

13. PI # 6 was admitted to the facility on 1/8/25 with a chief complaint of mental health.

Review of the record revealed a transfer to a higher level of care occurred on 1/18/25.

The MR failed to include documentation ED staff provided a report to the transport team.

An interview was conducted on 5/22/25 at 1:42 PM with EI # 2 who confirmed there was no documentation transport team report was provided per hospital policy.