HospitalInspections.org

Based on document review and interview it was determined for 1 (Pt #1) of 10 patient, the Hospital failed to ensure assessment and monitoring of patient status was completed per hospital policy. This has the potential to affect all in-patients receiving care from the Hospital.

Findings:

1. The policy entitled "Pressure Ulcer Prevention" (revised 5/2016) policy states "9. A. Mepilex dressings should be marked with the date and a 'P' for prevention. The dressing should be rolled back so the area can be assessed."

2. Pt #1 was admitted to the Hospital on 9/19/16 with a diagnosis of increase in spasticity of both upper and lower extremities. The clinical record was reviewed on 11/21/16 at approximately 11:00 AM. Documentation on the Plan of Care under Intervention: Consider use of anti-shear dressing. It was documented on 9/21/2016 at 9:33 AM thru 10/10/2016 at 10:36 AM an anti-shear dressing (Mepilex) was in place. There is no documentation in the chart by any registered nurse the dressing was rolled back and the area assessed.

3. An interview was conducted on 11/22/2016 at approximately 11:00 AM with the Director of Professional Practice (E #1). E #1 verified there was do documentation in Pt #1's chart the dressing was rolled back and the area assessed. E #1 further stated there is not a designated place to chart this assessment as it it not an actual wound. I would think the assessment would be entered in the wound area of the chart and marked "P" as a preventative measure.

Based on document review and interview, it was determined in 6 (Pt #1, 2, 3, 5, 6, and 8) of 10 clinical records reviewed, the Hospital failed to ensure the nursing care plan was followed with required patient interventions per Hospital policy to prevent skin breakdown. This has the potential to affect all in-patients receiving care from the Hospital.

Findings include:

1. Policy entitled Patient Care Policy/Procedure (revised 10/2016) policy states: "3. Patients with a Braden score of < 18 will be considered at risk and assessed for appropriate interventions according to MMC Pressure Ulcer Prevention policies/procedure. The lower the score, the higher the risk". " 4. When the Braden score is <18, the following nursing orders will be automatically initiated in ClinDoc and show on the order summary: A. Turn the patient. B. Elevate heels off the bed..."

2. Pt #1 was admitted to the Hospital on 9/19/16 with diagnosis of increase in spasticity of both upper and lower extremities. The clinical record was reviewed on 11/21/16 at approximately 11:00 AM. On 10/3/16, Pt #1's Braden score was 12. No documentation was found of turning and repositioning Pt #1 from midnight to 6 AM on 10/3/16.

3. Pt #2 was admitted to the Hospital on 11/19/16 with a diagnosis of intracranial hemorrhage (ICH). The clinical record was reviewed on 11/21/16 at approximately 11:45 AM. On 11/19/16 Pt #2's Braden score was 15. No documentation was found of
turning and repositioning Pt #2 from 2:00 PM to 6:00 PM on 11/19/16.

4. Pt #3 was admitted to the Hospital on 11/15/15 with a diagnosis of cerebral vascular accident (CVA). The clinical record was reviewed on 11/21/16 at approximately 1:30 PM. On 11/15/16 Pt #3's Braden score was 16. No documentation was found of turning and repositioning Pt #3 from 1:00 PM to 3:00 PM on 11/15/16.

5. Pt #5 was admitted to the Hospital on 9/14/16 with the diagnosis of seizures. The clinical record was reviewed on 11/22/16 at approximately 9:15 AM. On 9/15/16 Pt #5's Braden score was 14. No documentation was found of turning and repositioning Pt #5 from 7:00 AM to 4:00 PM on 9/15/16.

6. Pt #6 was admitted to the Hospital on 10/18/16 with a diagnosis of ICH. The clinical record was reviewed on 11/22/16 at approximately 9:30 AM. On 10/18/16 Pt #6's Braden score was 14. No documentation was found of turning and repositioning Pt #6 from 2:00 AM to 12:00 PM.

7. Pt #8 was admitted to the Hospital on 11/2/16 with a diagnosis of CVA. The clinical record was reviewed on 11/21/16 at approximately 10:45 AM. On 11/12/16 Pt # 8's Braden score was 12. No documentation was found of turning and repositioning Pt #8 from 12:00 AM to 6:00 AM.

8. On 11/22/16 at approximately 9:45 AM an interview with the Director of Professional Practice (E #1) was conducted. E #1 checked for further documentation and found no other entries to explain the gaps in turning and repositioning for the indicated patient's clinical records reviewed.

Based on document review and interview, it was determined in 1 of 10 (Pt #8) clinical record reviewed, the Hospital failed to ensure adherence to infection control policy and procedure to help reduce and/or prevent the spread and cross contamination of infectious organisms. This has the potential to affect all in-patients receiving care from the Hospital and staff and visitors.

Findings:

1. The policy titles "Infection Prevention and Control Manual Category: Isolation (Last reviewed 8/24/2016) was reviewed on 11/22/2016 at 10:00 AM. The policy indicates under "II. Procedures N. Visitors are instructed about the isolation".

2. Pt #8 was admitted to the hospital on 11/2/2016 with a diagnosis of Cerebral Vascular Accident (CVA). Pt #8 had a history of C-Diff (Clostridium difficile) and was placed in contact isolation upon admission. On 11/6/2016 at 9:30 PM the physician was notified Pt #8 was positive for C-Diff and contact isolation continued. There is no documentation in the chart indicating the family was educated on isolation precautions.

3. An interview was conducted with Director of Professional Nursing Practice (E #1) on 11/21/2016 at approximately 1:00 PM. E #1 reviewed Pt #8's chart with writer and verified there was no family education documented.