HospitalInspections.org

A. Based on medical record review and staff interview, it was determined that the facility failed to ensure the mitigation of risks to possibly contribute to healthcare-associated infections specific to indwelling catheters.

Findings include:

1. The medical records of Pt #1 were reviewed. The record with the admission date of 11/29/09 indicated the patient was admitted with diagnoses of Pneumonia and Abscess in the Presacral Area. A physician's "Report of Operation", dated 12/5/09, indicated under, " Procedure: I was called by the nursing staff and surgeon on call for dislodged G-tube on 12/5/09. The patient had pulled out her G-tube button with the balloon intact. This contained about 3cc of saline. The tube was retrieved from the trash, cleansed and inserted back into the G-tube site in the left upper quadrant. The balloon was checked and was intact without evidence of leak. 10cc of saline were instilled to prevent G- tube becoming dislodged again .... "

2. During interviews with the Chief Executive Officer, VP and Chief Operating Officer, and Director of Infection Control, conducted on 3/2/10 at 2:30 PM, the above finding was confirmed.