Name   Schawana Stidham, PI Director   [CPN]
E-mail    schawana.stidham@narh.mh.alabama.gov
Facility Name  North Alabama Regional Hospital (NARH)_2Ad*HBIPS
Facility CEO    Randy Phillips
Facility Address    4218 Highway 31 South, Decatur, Alabama

Jt Com Org ID#    655

# Beds - Adult    74
# Beds - Child & Adol   
# Beds - Sub Abuse   
# Beds - Forensic  0
# Beds - MR/DD    0
# Beds - TotaL    74
# Beds - CMS Distinct Part    74

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    May 22, 2009
Survey Days (e.g., Mon - Weds)    Mon- Thurs.
Number of Surveyors    3
Priority Focus Areas   
Last Survey Ending Date    5/3/06

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)   Jay S. Flocks, M.D.  Would get focused on one issue and would discuss that topic the rest of the session.  Wants to see statistically analysis.
Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)   Virginia J. Jordan, MSN, RN.  Would get focused on one issue.
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)    William (Bill) H. McCully, CHFM.  Pleasant and thorough.focused on Infection Control  Disaster Planning
 

# of Non-Compliant Standards    10 (3 Direct/7 Indirect)

APR/NPSG Cites 

• NPSG.01.01.01 EP#1 & EP2:  There was not "active" patient involvement in the identification process.  Two identifiers were not used prior to giving medication.

• NPSG.02.03.01 EP#5:  Data for the timeliness of reporting of "critical test results" had begun but there was not a track record.

MM/PC  Cites

• MM.01.01.03 EP#4:  Insulin was not separated as to type of insulin and not marked with high risk labels.  Additionally, two nurses did not check correct dose, as is standard practice.
  

• MM.04.01.01 EP#13:  Pre-printed Standing Orders:  "minor pain" was not defined and "fever" was not defined.  Physicians' signatures were illegible.  Order for PO or IM administration, but no parameters were given to the RN as to when to use each route.

RC/RI  Cites

IC/WT Cites

•  IC.01.05.01 EP#1:  Fit testing had not been completed on staff for the N-95 facial mask.

HR/LD Cites

IM/PI Cites

• P1.02.01.01 EP#3:  Did not utilize statistical tools to analyze, compare and display the data

EC/EM//LS Cites 

• EC.02.06.01 EP#1:  (Clarification submitted to TJC and EP was removed). Patient beds were not secured to the floor which could allow a patient to left the bed while under it and drop it on his chest/neck in a suicide attempt.  Faucet controls in the patient bathrooms designed that they could support a ligature for hanging. 
• EC.04.01.01 EP#15:  Objectives, Scope, Performance, and Effectiveness of the EOC Plans were not addressed.  An annual evaluation had been completed, but surveyors did not feel it was adequate.

IF an emergency management tracer was conducted using a mass casualty simulation, please indicate which scenario was used.   

MS/NR Cites (Stnd#/EP#/Brief Descrip/Surveyor)

• MS.06.01.03 EP#6: (Clarification submitted to TJC and EP was removed).
  Physical Therapist should have been credentialed and privileged.
• MS.06.01.07 EP#4:  Clarification submitted to TJC and EP was removed).  Physical Therapist had not been granted privileges licensed practitioners and was not subject to OPPE or FPPE reviews.
• MS.06.01.07 EP#5: Psychiatrist had been granted the privilege of History and Physical Examination even though he had not performed any in the previous two years.
• MS.08.01.03 EP#1:  OPPE process was not clearly defined.  Data being monitored was not meaningful or evidence based.

**Surveyor Compliments (Policies, Procedures, etc noted by which surveyor)

Preliminary Survey Result    JC: Accreditted, No RFI

**Misc Comments, Suggestions, Etc    **Misc Comments, Suggestions, Etc

• Note: Initially we received 9 indirect, however, clarification (x) was provided on 3 EPs and all three EPs were removed.

North Alabama Regional Hospital (NARH) had a total of 3 Direct Impact Findings:
1- NPSG.01.01.01 EP#1
2- NPSG.01.01.01  EP#2:
3- MM.01.01.03 EP#4
NARH ultimately had 7 Indirect Impact Findings (see also Misc Comments above).
1- NPSG.02.03.01 EP#5
2- MM.04.01.01 EP#13
3- IC.01.05.01 EP#1
4- P1.02.01.01 EP#3
5- EC.04.01.01 EP#15
6- MS.06.01.07 EP#5
7- MS.08.01.03 EP#1
X- xEC.02.06.01 EP#1
X- xMS.06.01.03 EP#6
X- xMS.06.01.07 EP#4

Schawana Stidham