| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 013434 | (X3) Date Survey Completed 02/01/2018 |
| Name of Provider or Supplier River Region Family Medicine | Street Address, City, State 41 Cambridge Court, Wetumpka, AL | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| E0000 | A recertification survey was conducted on 2/1/18 and the facility was found to be in compliance with the Condition of Participation, Appendix Z, Emergency Preparedness Requirements. |
| J0022 | MAINTENANCE CFR(s): 491.6(b)(1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This STANDARD is not met as evidenced by: Based on review of the refrigerator logs and interviews with the staff it was determined the facility failed to ensure each refrigerator temperature was documented on a daily basis. This had the potential to negatively affect all patients served by the facility. Findings include: A tour of the facility was conducted on 1/31/18 at 9:00 AM with Employee Identifier (EI) # 1, Assistant Manager, who informed the surveyor the clinic was divided up into halls. Laurenzi Hall with exam room # 1, # 2, and # 3 and a Triage room with a refrigerator and extra office with a refrigerator. Lyons Hall with exam room # 1, # 2 and # 3. Murphy's Hall with exam room # 5 and # 6 and a Triage room with a refrigerator. Kent's Hall with exam room # 1, # 2 and # 3. Review of the refrigerator temperature logs from Laurenzi Hall in extra office, Murphy's Hall in the triage room, EI # 7, Operator, area which all stored patient medications revealed the following: The logs for the refrigerator from Laurenzi Hall in the extra office had not been updated since September 2017. The logs from Murphy's Hall in the triage room were not completed since November 2017. The refrigerator in EI # 7 office has a thermometer but no documentation a temperature log was kept for this refrigerator. An interview was conducted on 2/1/18 at 1:15 PM with EI # 1, Assistant Manager, who confirmed the above mentioned findings. |
| J0023 | MAINTENANCE CFR(s): 491.6(b)(2) Drugs and biologicals are appropriately stored; and This STANDARD is not met as evidenced by: Based on observations, policy and procedure manual documentation and interviews with the staff it was determined the clinic failed to ensure all medications and supplies available for patient use were not expired and were stored safely. This had the potential to negatively affect all patients served by the clinic. Findings include: River Region Family Medicine Policy and Procedure Expired Sample Medications "All sample medications in the sample closets are inventoried monthly and all expired samples are placed in the facilities biohazard closet. They will then be picked up and signed for by authorized hospital personnel and taken to Elmore Community Hospital". A tour of the facility was conducted on 1/31/18 at 9:00 AM with Employee Identifier (EI) # 1, Assistant Manager, to observe medication and supply storage. During the tour each of the four halls were checked separately. Laurezi Hall: Exam Room # 1 1 - 16 oz bottle Hydrogen Peroxide opened and no open date on the bottle 1 - box tongue depressors expired 11/17 Exam Room # 2: 23 - tongue depressors expired 11/17 5 - packs cotton tipped applicators expired 11/17 Triage Room: 1 - single vial dose bottle of Ketorlac Tromethamine 60 mg (milligrams) / 2 ml (milliters) opened and not disposed of after use. Extra office with refrigerator on Laurenzi Hall: 2 - Repatha 140 mg/ml expired 12/17 2 - Toujeo 300 Units/ml expired 5/17 1- Toujeo 300 Units/ml expired 8/17 1 - Praluent Alirocumab 75 mg/ml expired 2/17 10 - 2 ml vials Iron Dextran 100 mg/ 2 ml expired 3/17. Lyons Hall: Exam Room # 1: 1 - Ipratropium Bromide Inhaler Solution 0.02% expired 10/12 1 - Ipratropium Bromide Inhaler Solution 0.02% expired 12/12 1 - open bottle Sodium Chloride Irrigation Solution expired 12/12 6 -Polylined Sterile Field packs expired 12/13 1 - Polylined Sterile Field pack expired 10/12 1 - pair purple Nitrile gloves opened 15 - packs Iodine pads expired 4/15 2 - 16 ounce bottles Hydrogen Peroxide open and no open date on bottle 1- bottle HemaScreen expired 5/13. Exam room # 2: 1 - 16 ounce bottle Hydrogen Peroxide open and no open date on bottle. Murphy's Hall: Exam Room # 5: 4 Packs - Iodine Swabs expired 10/17 Laboratory: 1- bottle 8.4% Sodium bicarbonate 84 mg/ml bottle open with no date opened 1 - bottle Nitrostat 0.4 mg/tablet expired 10/17. Kent Hall: Exam Room # 3: 6 - bottle 0.9% Sodium Chloride 250 cc (cubic centimeter) expired 3/16. Crash Cart Adult: No medications in crash cart EI # 2, Lab Tech, stated all the medications were expired and had been removed and new medications were ordered but had not received them. 2 - 3 ml syringes expired 12/17 1 1000 cc bag of Normal Saline (NS) expired 4/17 Crash Cart Pediatrics: No medications in crash cart EI # 2 stated all medications were expired and had been removed and new medications were ordered but had not received them. 2 - 3 ml syringes expired 12/17 1 - 1000 cc bag NS expired 4/17. Sample Medication Room: 1 -Flovent HFA (Hydrofluoroalkanes) 110 mcg (micrograms) expired 12/17 1 - Pennsaud 2% topical solution expired 12/17. Further review of the Sample Medication Room revealed no medication logs available for staff to sign out medications for facility patients. An interview was conducted on 2/1/18 at 1:15 PM with EI # 1, Assistant Manager, who confirmed the above mentioned findings and initiated a log for the Sample Medication Room. |
| J0055 | PATIENT CARE POLICIES CFR(s): 491.9(b)(1) The clinic's ... health care services are furnished in accordance with appropriate written policies which are consistent with applicable State law. This STANDARD is not met as evidenced by: Based on observations, the facility policy and procedure manual, review of Potter and Perry's Fundamentals of Nursing, Center for Disease Control (CDC) and interviews with the staff it was determined the facility failed to ensure their policy and procedure was followed for infection control and to ensure all staff followed appropriate infection control procedures for handwashing and glove changing. Findings include: Hand washing: Policy and procedures Ivy Creek Healthcare Purpose: To cleanse the hands of germs and prevent contamination between patients and home care personnel. Policy: All personnel providing direct or indirect care/ service will wash their hands...prior to contact with the patient. Personnel also will wash their hands: after gloves are removed when hands are visibly soiled... Potter and Perry's FUNDAMENTALS OF NURSING EIGHTH EDITION, Chapter 28. Copyright 2013, "Infection Prevention and Control " page 419 revealed: " ...Change gloves and perform hand hygiene between tasks and procedures on the same patient after contact with materials that contains a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items ...Perform hand hygiene immediately to avoid transfer of microorganisms..." Hand Hygiene CDC Guidelines Last updated: March 25, 2016 When to Perform Hand Hygiene a. Before Eating b. Before and after having direct contact with a patient's intact skin (taking pulse or blood pressure, performing physical examinations...) c. After contact with blood, body fluids or excretions, mucous membranes, non-intact skin or wound dressings. d. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. e. After glove removal... 1. A patient observation with Patient Identifier (PI) # 21 was conducted on 1/31/18 at 10:55 AM with Employee Identifier (EI) # 4, Medical Assistant. PI # 21 was taken to the triage area for vital signs and medical information concerning the visit. EI # 4 did not have gloves on and took PI # 21's vital signs and documented on the computer. EI # 4 then donned gloves and did not wash hands prior to donning the gloves and conducted a flu swab. EI # 4 escorted PI # 21 to an exam room to be seen by the nurse practitioner. The surveyor observed EI # 4 entering the exam room with a syringe. The surveyor observed EI # 4 don gloves without sanitizing hands and gave PI # 21 an injection of Decadron and Medrol to the right hip. EI # 4 removed gloves and failed to wash hands prior to leaving the exam room. 2. A second observation was conducted on 1/31/18 at 11:30 AM with EI # 4 and PI # 22 to observe the drawing up of medication and administration to the patient. EI # 4 was in the triage room and sanitized hands and began to draw Decadron from the bottle and failed to clean the rubber stopper prior to insertion of the needle. EI # 4 then inserted same needle into a second bottle which contained Medrol and drew the medication up and failed to clean the rubber stopper of the bottle prior to insertion of the needle. When complete EI # 4 removed gloves and donned a clean pair of gloves without sanitizing hands. EI # 4 entered Exam room to administer the medication. EI # 4 with the same gloves on administered the medications to PI # 22 to the left hip area. EI # 4 removed gloves and failed to sanitize hands prior to leaving the exam room. 3. A patient observation was conducted on 2/1/18 at 8:05 AM with EI # 8, Medical Assistant, and PI # 23 to observe the patient visit. The patient was brought to the triage room and EI # 8 took PI # 23's vital signs and documented in the computer and did not wash or sanitize hands before or after vital signs were taken. EI # 8 then reviewed the patient's medications with the patient and escorted the patient to exam room # 6 to be seen by the nurse practitioner. EI # 8 returned to the triage room and documented on the computer and failed to sanitize hands. EI # 8 then obtained forms and placed them in a folder for review by the nurse practitioner and returned to triage room where EI # 8 donned gloves without sanitizing hands and drew up a B 12 injection in a 3 cc (cubic centimeter) syringe without cleaning the rubber stopper of the medication bottle. At 8:30 AM EI # 6, nurse practitioner, entered the exam room to speak with PI # 23. EI # 6 had a tablet in hands for documentation. EI # 6 placed the tablet on the counter in exam room # 6. EI # 6 failed to sanitize hands prior to entering patient's exam room. EI # 6 assessed the patients lungs and heart and spoke with the patient for several minutes. EI # 6 then documented on a form and in the tablet and failed to sanitize hands before or after assessment of the patient and before documenting on the tablet. EI # 6 failed to clean the tablet after sitting the tablet on the counter and prior to exiting the exam room. An interview was conducted on 2/1/18 at 1:15 PM with EI # 1, Assistant Manager, who confirmed the above mentioned findings. |