HospitalInspections.org

Based on interview, record review, hospital policy and procedure review and observation, it was determined that the facility failed to ensure wound care was furnished or supervised by a Registered Nurse to provide wound care to meet the needs for 4 of 4 current patients (#'s 4, 21, 23, & 24) reviewed with wound care.

Failure to ensure the appropriate licensed, educated, qualified and trained nursing staff provided nursing care created potential for deterioration and/or delay in wound healing, and infection to all patients with wounds. (Refer to A-0395).


Findings include:


Interview on 6/8/2016 at 11:35 a.m. with the Wound Team Coordinator (Staff #E) revealed the Director of Nursing Services (DON) had resigned two days prior (6/6/2016). Staff #E stated that this DON had implemented the Wound Team approximately 2.5 years ago and that Staff #E was initially the only person on the team. Once the need for wound care treatment increased, the DON implemented Certified Nursing Assistants (CNAs) on the team. One of the CNAs (Staff #D) was hired on 2/18/2015 and CNA (Staff #C) was hired on 3/6/2016.


- Review of the hospital job description/evaluation form for WOUND CARE TECH (Date initiated was not identified) stated the "Wound Care Tech will assist the Wound Care Coordinator with patients receiving wound and/or lymphedema care. The Wound Care Tech is responsible for applying wound dressing as directed by the Therapist or RN. Takes and prints photographs of weekly wound assessments, maintains adequate levels of inventory, reports changes in patient status and other duties as assigned." Certifications that were required for this position included Certified Nurse Assistant and basic life support certification.


- The job description did not include direction to unlicensed staff to independently and without RN supervision remove wound dressings, apply biologicals or medications, measure, assess and reapply dressings. Review of Staff #C and Staff #D's employee files revealed they were not licensed to independently provide nursing services without the direct supervision of a Registered Nurse. Staff #C and #D were observed providing wound care to patients.

Based on interview, observation and record review the hospital failed to respond to patient requests for assistance in a manner that maintained or enhanced their dignity for 4 of 7 sampled patients (#'s 2, 5, 21 and 23). This failure placed all residents at risk for potential psychosocial harm from not being able to participate in their health care decisions.


Findings include:


1) Patient #2 was admitted to the hospital on 5/18/16 for post-surgical recovery. Prior to hospitalization the patient was independent at home and reported she was continent of bowel and bladder. Patient #2 was transferred from an acute care hospital to Promise Hospital for recovery from surgery and for rehabilitation with the intent to return home. Patient #2 arrived to the facility with an indwelling Foley catheter (a tube inserted into the bladder to drain urine).

Interview with Patient #2 on 6/7/16 at 4:00 p.m. revealed that the patient had requested to wear an incontinent brief so that she would not be incontinent in the bed. She told this surveyor that she wanted her dignity and did not want to have a bowel movement in the bed. Patient #2 stated that staff had instructed her to go in the bed. Patient #2 stated, "Patients are to have rights. Do I have any?"

- Record review and interview with Patient #2 on 6/8/16 at 2:00 p.m. revealed she had her Foley catheter removed at 4:30 p.m. on 6/7/16. She did not have an incontinent brief on. She said that she had an incontinence pad under her. She said that physical therapy staff puts an incontinent brief on during her daily therapy and then they take it off. She stated that when the incontinent brief is off she worries about having a bowel movement or urinating in the bed. The patient stated that she was able to walk using handrails while the physical therapy staff stand-by and supervised. Patient #2 stated she was not offered assistance to walk to the bathroom when she needed to be toileted.

Interview of LPN #O on 6/9/17 at 9:45 a.m. revealed that the patient had a care plan that indicated the patient was to use an incontinent pad placed under her or to use the bed pan. He said the patient had 2 bowel movements with urination during the previous night. When asked what he would do if the patient requested an incontinent brief, he said he was not sure if they [the hospital] provided them. He said the patients put on their call lights if they need to go to the bathroom and it is not the practice for patients to void in their beds.

- Although Patient #2 was able to walk, she had not been offered assistance to walk to the bathroom or offered the use of a bedside commode.

Interview with Patient #2 on 6/9/16 at 9:55 a.m. revealed that staff members had to do three complete bed changes during the night shift because she had voided and had bowel movements on the incontinent pads. She said she did not get any sleep. She said she still preferred to wear an incontinent brief so that she could sleep at night.

Interview with Physical Therapist P (PT #P) on 6/9/16 at 10:00 a.m. revealed Physical Therapists make the recommendations to the nurses regarding patients' advancement in their ability to ambulate to the nurse. It was noted that patient #2 was able to tolerate ambulating to a bed side commode.

Interview with the Administrator (Staff #A) on 6/9/16 at 10:15 a.m. revealed incontinent briefs are used on an individual basis per patient's request. The facility provides the incontinent briefs and it is the expectation of the staff to do hourly rounds and check for "pain, potty and position."


2. Patient #23 was admitted to the facility for wound care. The patient was alert and able to make health care decisions. Observation of Patient #23 on 6/7/16 at 2:05 p.m. revealed he was talking on his cell phone when Staff #E took a picture of his wound located at his lower back. The patient was unaware that Staff #E was taking photos of his wound.

Patient #23 was very upset and wanted to know why his picture was taken before he was informed or asked. Staff responded that he signed a paper at admission permitting photos to be taken. The patient said it must have been small print, "I guess I have no choice in it."


3. Patient #21 had contractures (lack of full range of motion) in both upper arms. The patient was dependent on staff members for all activities of daily living including mobility and ensuring her needs were met.

Observation of patient #21 on 6/6/16 at 12:55 a.m. revealed that the patient did not always have her call light within reach. The patient needed to have the call light placed so that she could easily activate it to summon help. The patient said she often feels like the staff treat her like a "rag doll" with their "rough handling" while they turned her from side-to-side in the bed for wound care. The patient also stated that her pain is not controlled before staff turn her for the dressing changes to her wound.


4. Interview with Patient #5 on 6/7/16 at 9:10 a.m. revealed she reported to staff members that her money and personal items that were on her bedside table were missing. Interview with LPN #U revealed that she will try to locate the missing money and personal items. On 6/8 and 6/9/2016 the patient was out of the facility. On 6/9/2016 the facility had no further update on the patient's belongings.

Based on record review, staff interview and observation, the facility failed to provide Registered Nurse (RN) supervision of the 2 wound technicians, Certified Nurse Aides (CNAs) performing wound care to 4 of 4 current patients (#'s 4, 21, 23 & 24) reviewed for wound care.

Failure to provide supervision of nursing care to patients receiving wound care placed all patients with wounds at risk for improper treatment of wounds, inaccurate assessment of wounds by unqualified staff, the development of infection and new skin issues.

Findings include:

1. Observation on 6/6/16 at 12:55PM showed Staff #D, (CNA) performing wound care to Patient #21 without a printed copy of the wound orders available to refer to, and assisted by Staff #C (CNA). The wound care consisted of removing an old dressing, assessing and applying new wound care and wound V.A.C. (V.A.C. therapy is a medical device system that promotes wound healing by delivering negative pressure (a vacuum) to the wound through a patented dressing and therapy unit creating an environment that promotes the wound healing process. This negative pressure helps draw wound edges together, remove wound fluids and infectious materials and promote granulation tissue formation (the connective tissue in healing wounds) was completed by the CNAs. There was no Registered Nurse to supervise or document the wound care on the medical record. The procedure was completed and then the CNAs moved on to the next patient.

1a. Observation on 6/8/16 at 9:50 a.m. of Patient #21's wound care and application of a wound V.A.C. and dressing changes revealed Staff #C and #D with assistance from Staff #S, all CNAs, performed the application of wound V.A.C without supervision of a RN.

2. Observation on 6/7/16 at 8:35AM showed Staff #D, (CNA) performing wound care to a Patient #4 who had loose stool with possible infection. The removal of the old dressing, assessment of wound site and dressing of the wound site was completed by the CNA. There was no Registered Nurse present and no documentation completed on the medical by licensed staff.

3. Observation on 6/7/16 at 2:05PM revealed Staff #D, (CNA) performing wound care to Patient #23 after being seen by Staff #X (Medical Doctor). The wet-to-dry dressing had been removed after Staff #X assessed it and gave verbal orders for the dressing. The new dressing was applied and the wound vac re-applied by Staff #D. Staff #D went by what s/he remembered Staff #X stated during the visit and not by the written orders. There was no Registered Nurse supervision and no documentation completed on the medical record by Licensed Staff.

4. Observation on 6/8/16 at 9:10AM revealed Staff #D, (CNA) performing wound care to Patient #24 after the patient had been assessed by Staff #Y (Physician Assistant) PA. Staff #Y consulted with Staff #D a CNA about the wound and her recommendations for care. Wound care was discussed and Staff #D performed the wound care by what s/he remembered Staff #Y told her. The dressing change was completed by Staff #D with no Registered Nurse or Physician Assistant supervision and documentation on the chart was not completed by Licensed Staff.

5. Interview on 6/8/16 at 11:30AM revealed Staff #D stating s/he was not sure how the nurse charted the wound care in the medical record. Staff #D said s/he was not sure how Staff #E charted in the medical record. Staff #D reported s/he did not need to look at the medical record for the current wound care order as s/he could remember in her head what the doctor said the last time. Staff #D was asked to read the wound care orders for two different wounds and could not interpret the order.

6. Interview on 6/8/16 at 11:45AM revealed Staff #V stated s/he was a new staff member and was still in training. S/he performed wound care on the weekends when the wound technicians Staff #C and #D were off. S/he was not sure who wrote in the wound record Monday through Friday when Staff #C and #D performed wound care. Staff #V was asked to interpret the same two wound care orders and s/he could not. S/he stated "I am a new Registered Nurse at this facility."

7. Interview on 6/8/16 at 11:50AM revealed Staff #W stated that Staff #C and #D chart on the wound care treatment sheet daily after they perform wound care. The Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) charted on it when they do an, "as needed" dressing change and on weekends. S/he said that everyone can chart on the wound care treatment log in the medical record. S/he said the RNs and LPNs are the only ones to record the wound care in the medical record. Staff #W was able to interpret 1 of 2 wound care orders.

8. Observation on 6/6/16 at 12:55PM Staff #C and #D were performing wound care to Patient #21. Two surveyors were present and noted a blister to the patients right hip. The blister was not addressed at the time of wound care. The blister was not reported to a RN or LPN and there was no documentation in the record to communicate the problem to other health care providers.

A second observation of Patient #21 on 6/8/16 at 8:30AM revealed Staff #C and #D removed an old dressing prior to Staff #Y doing her assessment on Patient #21. The wound to the coccyx was assessed and the wound care was administered to the coccyx and feet.

The patient cried out in loud pain as s/he was turned to her right side for the dressing change. When Staff #S turned the patient on to her back s/he noted a skin tear to the right hip and the patient said her skin hurt.

This was the site of the previous blister observed on 6/6/2016 by the surveyors.


Although staff provided wound care to the patient everyday, the blister was not identified for two days. Staff #E came in to look at the site and called the doctor for an order for treatment.


Record review on 6/8/16 at 3:30 for Patient #21 revealed Staff #E's assessment of wounds completed on 6/6/16 did not have any documentation of a blister to the right hip. The doctor's progress notes from 6/6/16 and 6/7/16 did not have any documentation of the blister to the right hip.


9. Random observation on 6/8/16 at 10:10 am of newly admitted patient revealed Staff #C and #D discussing a physician order for a dressing change on the new patient. Staff #C removed the order for Mepilex from the chart, took it to the pharmacy to be filled, pharmacy gave the Mepilex to Staff #C who then gave it to Staff #D who went into patient"s room, removed the soiled foam dressing, cleansed the area with gauze and applied the Mepilex with no supervision or wound assessment from RN.


10. During interview on 6/7/16 at 9:50 am with Staff #E, an RN, reported that s/he trained and supervised Staff #C and #D both CNA and classified wound technicians (techs) who do wound care and wound V.A.C. S/he reported that wound care techs do not document the wound care, nurses are supposed to go in with the wound techs and look at the wounds and document the wound appearance and care. All wound care is to be documented on the same wound care treatment record and the wound care team does not document on the wound care treatment record.


11. During interview on 6/8/16 at 10:20 with Staff #D, a CNA, wound care team member reported that s/he received training for wound V.A.C. and wound care from Staff #E and through education provided by the hospital including the annual skills fair.


12. During interview on 6/8/16 at 11:30 with Staff #C, the wound care team member reported that s/he writes down description and measurements of wounds on a piece of paper and gives hand written notes to Staff #E to document on the Bates Jensen form (wound care evaluation form used by the facility). Staff #C reported that the nurse was "always supposed to come" with wound techs when they perform wound care. Staff #C received wound care training from Staff #E.


13. During interview on 6/8/16 at 11:50 with Staff #Q, RN, s/he reported that s/he tried to go in with the wound care team who are CNAs to observe them measure and assess the wounds. Staff #Q then documented on the nurse' s notes and wound care evaluation forms. Staff #E charted what was reported to her on the Bates Jensen form.

14. During interview on 6/8/16 at 2:20pm of Staff #N, RN, s/he stated that the wound care team, Staff #C and #D, told her when they would do wound care and that s/he went in if s/he had the opportunity but was not always available if s/he was in another patient's room. Staff #N reported that s/he documented on the wound care treatment record that the wound care team (WCT) did a treatment.

Based on observation, record review and interview the hospital failed to ensure that the nursing staff developed, and kept current, individualized nursing care plans for 7 of 23 patients (#'s 3, 7, 10, 12, 13, 17 & 21) reviewed. Failing to have individualized care plans to meet the needs of each individual patient placed patients at risk for not having necessary care and services provided according to their assessment and potentially delayed improved well-being.

Findings include:

According to the American Nurses Association, the Nursing Process included planning based on the assessment and diagnosis of the individual patient, the nurse sets measurable and achievable short- and long-range goals for this patient that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the patient's care plan so that nurses as well as other health professionals caring for the patient have access to it. Implementation of Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient's record. Both the patient's status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.


1. Patient #13 was admitted on 4/22/16 with diabetes, end stage kidney disease with multiple wounds and discharged from the hospital to an acute care hospital on 4/30/16 after falling at the facility and fracturing his right hip.

Review of the interdisciplinary admission assessment (IAA)-Nursing, revealed a fall risk assessment section that indicated Patient #13 had unsteady/poor balance and was on multiple medications that put him at risk for falls.

Fall interventions were checked on the IAA-Nursing form and included: Assist patient with ambulation & transfer if applicable, patient and family education, call light and phone within easy reach, one-on-one transfer/ambulation, fall risk sign in place.

IAA-nursing also identified multiple wounds, altered skin integrity, potential/actual infection, wound care referral initiated, dietician referral initiated.

Patient #13's care plan was generic, not specific or individualized toward the patient's specific needs. Review of care plan with dates of 4/22/16 and 4/23/16, Musculoskeletal: impaired physical mobility, activity intolerance, fatigue, at risk for fall, trauma: interventions circled included: 1. Assess mobility every shift, 2. obtain PT/OT consult, 3. Manage pain.

The care plan had dates of 4/25/16 through 4/30/16 Musculoskeletal: impaired physical mobility, activity intolerance, fatigue, at risk for fall, trauma, interventions circled included: 1. Assess mobility every shift, 3. Manage pain. The "Desired outcome" on all dates was circled "Yes."

Review of physical therapy initial evaluation dated 4/29/16 revealed fall precaution for Patient #13, standing static and dynamic balance, sit to stand, moving from bed to chair, ambulation and gait deviations was not documented as tested.

There was no direction to staff caring for the patient to ensure Patient #13 was safe when he needed assistance with ambulating in the room or with toileting.

On 4/30/2016 at 8:20 a.m. Patient #13 was found on the floor in his room. S/he had gotten up on his/her own responding to toileting needs and slipped. S/he complained of right leg pain, s/he was assisted to bed by staff. The physician was notified and stat (immediate) Xray was ordered and revealed a right hip fracture.

Review on 6/9/2016 of the facility policy revealed the purpose of the Fall Prevention Protocol was to provide a method by which the clinician can: 1. Identify upon admission patients who are at risk for falls and provide ongoing assessment throughout their hospital course. 2. Provide methods and interventions designed to create a safe environment for every patient and to reduce the incidence of patient falls. 3. Provide education to the patients and their family so that everyone can contribute effectively to decreasing a patient's fall risk. 4. All patients admitted to Long-term acute hospital were considered a Fall Risk and there was no patient individualized specific interventions identified.


2. Patient #10 was admitted to the hospital on 4/11/2016 with cardiac, lung and kidney disjunction The patient had open heart surgery prior to admission and this information was noted in the patient's record. The patient had a sternal (mid-line of the chest) surgical incision that was approximated at admission and showed no signs and symptoms of delayed healing.

The patient was dependent on staff to meet all needs for activities of daily living including mobility and personal hygiene.

According to the patient's care plan he was identified to have impaired physical mobility, activity intolerance, fatigue and at risk for falls. There was no directions written for staff that described precautions to take so not to cause injury to the patient's sternal surgical site. There were no restrictions implemented for staff to follow when transferring the patient from his bed to his chair.

On 4/17/2016 and 4/18/2016 Patient #10 complained of sternal pain. On 4/22/20016 the patient was noted to have drainage from his sternal wound. On 4/25/2016 the patient was transferred to an acute hospital for surgical interventions for sternal dehiscence (is the process of separation of the bony sternum, which often is accompanied by mediastinitis (infection of the deep soft tissues).

Continued review of Patient #10's care plan indicated s/he had impaired skin. There was no direction documented in the care plan on how to provide skin care to the patient.

The patient was admitted on 4/11/2016 and discharged on 4/25/2016 to an acute hospital. The patient's documentation indicated s/he received 3 bedbaths during that time frame. A staff member at the receiving acute hospital stated that the patient was wearing a soiled gown and was unclean upon arrival.


3. Observation on 6/6/16 at 12:55PM patient #21 revealed the patient crying out in pain as s/he was being positioned for her wound dressing change. Staff #C and #D turned the patient to her right side and did not address the pain issue. Although the patient had pain medication ordered, no pain medication was given prior to the dressing change. Wound care was provided by 2 CNAs. Staff #C and #D never asked the nurse caring for patient #21 for any pain medication and did not have a nurse assess the patient's pain. The wound treatment was completed and the patient never received a pain assessment or pain medication.


Interview on 6/6/16 at 1:40 with Staff #B revealed Patient #21 had pain medications (Hydrocodone (narcotic) 5-7.5 mg) (mg is a milligram dosage for medications) available for "as needed" use. S/he clarified the patient was not medicated prior to the dressing change.


Record review on 6/6/16 revealed Patient #21 had an order for Hydrcodone/APAP 5mg that s/he could have every 4 hours as needed. S/he received no pain medication on the day shift from 7:00AM to 7:00PM.

4. Patient #15 was admitted on 4/19/16 with acute respiratory failure, a tracheostomy, chronic bleeding in her brain with part of her right skull removed, in an unresponsive state, diabetic with a feeding tube in her stomach for nutrition and a stage III pressure ulcer (a wound caused by pressure over a bony prominence with full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) on her sacrum (triangular bone in the lower back) Review of the patient's Care plan revealed a generic recipe-type care plan that was not specific or individualized toward the patient's specific wound care needs.


5. Patient #3 was admitted on 5/6/16 with multiple wounds and was discharged from the hospital on 6/6/16. The patient's care plan was generic and was not specific or individualized toward the patient's specific wound care needs.


6. Patient #7 was admitted on 2/3/16 with acute respiratory failure and severe brain injury and discharged from the hospital on 4/25/16. S/he developed stage II (shiny red or dry shallow open wound) pressure areas on both ears. The patient's care plan was generic, not specific or individualized toward the patient's specific wound care needs.


7. Patient #12 was admitted on 4/13/16 with foot and toe ulcers with infection in the bone of his right foot and discharged from the hospital on 4/19/16 to an acute care hospital for possible amputation of the right foot. The patient's care plan was generic, not specific or individualized toward patient's specific wound care needs.

Based on record review, staff interview, and observation, the facility failed to follow orders for wound care prescribed by the physician for 1 of 7 current patients (#15) and 4 of 13 discharged patients (#'s 3, 7, 12 & 13). Failure to provide physician ordered wound treatment placed patients at risk for delayed healing, infection and development of new skin issues.

Findings include:

1. Medical Record review on 6/7/16 at 11:45 am of Patient #15 revealed s/he was admitted on 4/19/16 with acute respiratory failure, a tracheostomy, chronic bleeding in his/her brain with part of his/her right skull removed, in an unresponsive state, diabetic with a feeding tube in his/her stomach for nutrition and a stage III pressure ulcer (a wound caused by pressure over a bony prominence with full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) on her sacrum (triangular bone in the lower back.)


Documentation on the patient's wound care treatment record revealed TREATMENT ORDERS/PLAN: 4/28/2016 SSD (silvadene, silver sulfadiazine, a cream used to prevent or treat bacterial infections of the skin)/Xeroform (a medicated, non-adhering, occlusive fine mesh gauze dressing) to sacral wound every 12 hours and as needed. 5/10/16 Add Triamcinolone Cream (a topical steroid) with silvadene then Xeroform then an absorbent abdominal pad every 12 hours and as needed.


Documented dressing changes for dates 4/26/2016 through 6/2/2016 showed that dressing changes were done 0 times on 7 of 38 days, 1 time a day on 23 of 38 days, 2 times a day on 8 of 38 days and only 2 of those days near a 12 hour interval prescribed by the physician.


The patient's 6/3/16 TREATMENT ORDERS/PLAN was as follows: Start Puracol AG (collagen fiber with silver to promote wound healing) slightly moistened then Xeroform, then Mepilex (an all in one foam dressing) boarder every 24 hours. Documentation revealed the dressing change was done on 6/3/16, 6/4/16, 6/7/16, 6/8/16. No documentation was found for the dates of 6/5/16 and 6/6/16.




2. Medical record review on 6/7/16 of patient #3, admitted on 5/6/16 with multiple wounds and discharged on 6/6/16 included documentation on Wound Care Treatment records as follows; ischial (buttock) deep wound, revealed documentation of wound treatment ordered to be done twice a day was not documented twice a day on 4 of 8 days. The left buttock and area between the anus and vagina revealed documentation of wound treatment that was to be done twice a day was not done twice a day on 9 10 days. Left heel wound treatment that was to be done daily starting 5/7/16 and ending 6/5/16 revealed documentation of wound treatment was not done on 18 of 30 days.


3. Medical record review on 6/7/16 of patient #7, admitted on 2/3/16 with acute respiratory failure and severe brain injury and discharged on 4/25/16 revealed s/he developed stage II (shiny red or dry shallow open wound) pressure areas on both ears. Physician order for barrier cream, Optifoam (and adhesive foam bandage) to bilateral ears, unspecific to how often to be applied. the Wound Care Treatment Record revealed no documentation of daily treatment on 14 of 29 days.


4. Medical record review occurred on 6/7/16 of patient #12, admitted on 4/13/16 with foot and toe ulcers with infection in the bone of his/her right foot and discharged on 4/19/16 to an acute care hospital for possible amputation of the right foot. Wound care and dressing changes were to be done every 8 hours per physician orders. The patient's Wound Care Treatment Record revealed that documentation of wound care as ordered occurred on 0 of 5 days. Flagyl powder (an antifungal deodorizing medication) was to be applied 2 times a day. The wound care treatment record revealed that documentation of wound care as ordered did not occur on 1 of 3 days.


5. Medical Record review on 6/7/16 of patient #13, admitted on 4/22/16 with diabetes, end stage kidney disease with multiple wounds and discharged on 4/30/16. Physician's order on 4/23/16 at 1130: Silvadene (a cream used to prevent or treat bacterial infections of the skin) to coccyx wound, unstageable, cover with xeroform and gauze - change twice daily. Betadine(an antiseptic iodine solution that rapidly kills a wide range of germs to prevent or treat an infection) to dead tissue on heel 2 times a day, Mepilex boarder to right elbow, stage III (a wound caused by pressure over a bony prominence with full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) daily, Mepilex boarder to right knee biopsy site daily. The wound Care Treatment Record, 4/23/16 through 4/30/16 reveal no documentation of wound care as ordered on 4 of 8 days.

Based on observation, interview and record review the hospital failed to ensure biologicals were administered in accordance with accepted standards of practice for 1 of 6 patients (#21) reviewed. This failure placed patients at risk for not receiving medications and/or biologicals according to physician orders, standards of practice and hospital policy.


Findings included:


1. Observation on 6/6/16 at 2:55PM revealed Staff #B assessed Patient #21 for complaints of nausea (feeling like you need to vomit). The patient said she wanted the "stuff" that lasted a long time. Staff #B told her that Zofran (a medication for nausea) had been stopped by the doctor and a new medication Phenergan (a medication for nausea) could be given.

The patient again wanted the Zofran because it lasted longer. Staff #B took an alcohol wipe (a small towelette soaked with a fluid of medical alcohol). Staff #B placed it under Patient #21's nose and told her to breath it in and it would take away her feeling of nausea.

Interview on 6/6/16 at 1:45PM revealed Staff #B explained that there was a study s/he was doing at his/her schooling that stated an Alcohol wipe under the nose would take away the feeling of nausea. S/he had found it to be successful with other patients.

Record review on 6/7/16 at 7:15AM revealed no documentation of Staff #B using the alcohol wipe to relieve the nausea for Patient #21. Record review showed the Phenergan was given at 8:00 a.m. and 4:00 p.m. which were the scheduled doses. There was no doctors order for using the alcohol wipes as a treatment for nausea.

Cross reference Federal Tag 0396--Certified Nursing Assistants applied medications and biologicals to patient wounds without the direct supervision of a Registered Nurse.

Based on observation, interviews and policy and procedure reviews the facility failed to perform practices to prevent and control infections and communicable diseases of patients and personnel which would put all staff and patients at risk for harm by the following:

1. Not cleaning equipment before placing in a clean storage area.
2. Not performing hand hygiene when required.
3. Allowing the foley bag and other drainage bags to touch the floor.
4. Taking contaminated items (camera strap, stethoscope, magnifying glass) from one patient's room to another without disinfecting in between patients.
5. Not cleaning velcro on the blood pressure cuffs in between patients
6. Not disinfecting a patient's over the bed table after using it to perform a dressing change.


Findings included:


1. Interview and observation on 6/8/16 at 12:00 pm of Staff #P, a Registered Nurse (RN) who performed dialysis for the hospital reported that the blood tubing was placed in a biohazard bag in the patients' rooms and disposed of in a locked dirty utility room. The dialysis machine was cleaned in the patients' rooms with a bleach wipe. Water tanks and a bicarbonate jug were taken to the dialysis storage room before being wiped down. Staff #P was observed rinsing a bicarbonate jug with water, s/he reported that the jug did not need to be wiped down but agreed that there was potential for contamination by blood.


2. Interview and observation on 6/8/16 at 1:00 pm with Staff #R, RN, who performed dialysis for the hospital confirmed that all equipment including the water tanks and bicarbonate jugs are to be wiped down with disinfectant wipes before taken to the dialysis storage room. Staff #R was observed wiping down all dialysis equipment in a patient's room prior to taking it to the dialysis storage room.


3. Observation on 6/8/16 at 10:30 a.m. of wound care of Patient #15 revealed that Staff #C continued to assist with wound care and dressing change after cleaning up bowel movement without changing gloves or washing hands.


4. Observation on 6/6/16 at 2:05 p.m. revealed the foley catheter drainage bag was on the floor of Patient #2. This practice potentially could introduce bacteria and other pathogens to the patient and put him/her at risk for disease.

Observation on 6/7/16 at 10:15 a.m. revealed the foley catheter drain bag of the Patient #2 was on the floor. The staff failed to follow policy and procedure for care of the foley catheter bags and put the patient at risk for exposure of infectious diseases.


5. Observation on 6/7/16 at 4:30 p.m. revealed the rectal tube drain bag on the floor of Patient #25. This has the potential of introducing infectious diseases to the patient and causing harm. The staff failed to follow policy and procedure to prevent infection control.


6. Observations on 6/7/16 Staff #C, #D, #E, and #X revealed while assessing and performing wound care hand hygiene (wash hands with soap and water or use hand sanitizer) before putting on gloves or between glove changes was not performed during care for patients's #4, 5, 15, 21, 23, 24 and 25.

7. Observation on 6/7/16 of Staff #C, #D, and #E revealed use of a camera strap touching contaminated areas on the patient or bedding and then put into the pockets of Staff #C, #D, and #E without being disinfected and then taken to another patient's room.

8. Observation on 6/7/16 from 1:10PM to 2:05PM of Staff #C and #D revealed use of a lighted magnifying glass used to make rounds with Staff #X to patients # 26, 17, 27, 28, 15 and 23. The magnifying glass was not disinfected between patient rooms and placed in Staff #C's pocket between patients.

9. Observation on 6/8/16 revealed Staff #R did not clean the blood pressure cuff used on the dialysis patients between use. The blood pressure cuff was approximately 2/3rds full of cloth remnants on the Velcro of the cuff.


10. Observation on 6/8/16 at 8:30AM of Patient #21 and on 6/8/16 at 9:10 a.m. of Patient #24 revealed Staff #D cleaned (with a sani wipe) only half of the patient's bedside table for the wound care and reached over the patient's personal items with her dirty gloves while performing wound care.


11. Observation on 6/7/16 from 1:10 p.m. to 2:05 p.m. revealed Staff #X failing to clean his stethoscope 5 out of 6 times after placing it on the patient (some on their direct skin) from room to room.

12. Observation on 6/7/16 at 8:35 a.m. revealed Staff #C and #D cleaning up Patient #4 being tested for C-Diff (an infection in the stool). The right lower part of her gown had stool on it and a clean pillow was placed on top of it. The pillow was then moved under the patient so she could be off of her back and the gown was changed. This did not remove the infectious stool from the patient or the staff to touch.

13. Observation on 6/7/16 at 1:25 p.m. revealed Staff #D while wearing dirty gloves used to do wound care took the patient's personal cell phone and took a picture of the wound and then set the cell phone on the patient's bed side table with the same dirty gloves on. The patient then picked up the phone with his/her bear hands to look at the picture of his/her wound. The patient was on contact precautions.

14. Interview on 6/6/16 at 1:20 p.m. revealed that Staff #D explained the hand hygiene policy was to wash hands before and after glove changes. S/he was not aware it was to be done between glove changes.


15. Interview on 6/8/16 at 1:00 p.m. revealed Staff #R was not aware that the Velcro on the blood pressure cuffs were a carrier for infection and needed to be cleaned between patient use.