HospitalInspections.org

Based on review of policy and procedures, medical records and interview with staff, it was determined the nurse executive failed to develop and keep current a nursing care plan for patients with non-surgical wounds, for 4 of 4 patient records that were evaluated (Patient #'s 4, 12, 16 and 28). This deficient practice could delay patient care, lead to poor patient outcomes and inappropriate discharge planning.

Findings include:

The hospital policy titled, "Mt. Graham Regional Medical Center, Patient Care Planning" requires the following: "...Each patient's nursing care is based on identified patient care needs and patient care standards...each patient will have care planned by a multidisciplinary team utilizing admission assessment data...the plan of care will guide patient care staff in providing care to the patient...."

Patient # 4

Patient #4 was admitted on 11/20/17 with fluid overload, methicillin resistant staph aureus (MRSA) in urine and wound, urinary tract infection, weakness, decubitus ulcer, leg ulcer, malnutrition, and constipation. Review of the medical record 11/27/17 through 11/30/17 revealed the following: pictures of wounds on the leg and buttocks. Wound care treatment and care plan documentation related to open wounds was not documented in the record.

RN House Supervisor #44 confirmed in an interview conducted on 11/28/17 and 11/29/17 that nursing staff failed to initiate a care plan to address the care of the open wounds.

RN #49 and RN Nurse Manager of Medical Surgical and ICU #13 confirmed in an interview conducted on 11/28/17 that the wound to the buttocks looks worse than when the patient came in..."

Patient # 12

Patient #12 was admitted on 11/24/17 and discharged on 11/28/17. Review of the medical record on 11/29/17 revealed the following:

The Emergency Room report 11/24/17 revealed: "...stage II pressure ulcer towards midline on the left buttocks...pressure sore in the sacral region was cleaned and bandaged appropriately..."

History and Physical on 11/25/17 states: "...local wound care for stage II sacral decubitus. Discussed with RN...."

No documentation was found regarding care of an open wound or skin integrity. The type of treatment performed, wound characteristics or wound measurements were not documented in the medical record.

RN Director of Regulatory compliance #1 confirmed in an interview conducted on 11/30/17, that nursing failed to initiate a care plan that addressed skin integrity or wound care.

Patient # 16

Patient #16 was admitted on 11/27/17, and discharged on 11/28/17, for cellulitis of the left lower extremity, chronic venous stasis ulcer, hypokalemia, concerns for peripheral arterial disease, and history of deep vein thrombosis. Review of the medical record on 11/29/17, revealed the following: pictures of an ulcer on the lower left leg. Wound care treatment and care plan documentation could not be located in the record.

RN House Supervisor #44 confirmed in an interview conducted on 11/29/17, that nursing staff failed to initiate a care plan to address wound care or skin integrity.

Patient # 28

Patient #28 was admitted on 11/27/17, post fall, intractable lower back pain, gait instability, chronic obstructive pulmonary disease, and hypoxia. Review of the medical record on 11/29/17 at 0920, revealed pictures of lacerations on the arms. Wound care treatment and care plan documentation could not be located in the medical record.

RN House Supervisor #44 confirmed in an interview conducted on 11/29/17, that nursing staff failed to initiate a care plan that addressed wound care or skin integrity.

Based on review of hospital policies and procedures, medical records and staff interviews, it was determined the administrator failed to ensure that the nursing staff documented wound care for 4/4 patients (Patient #4, 12, 16, and 28) with non-surgical wounds.

Findings include:

The Hospital's policy titled "Mount Graham Regional Medical Center, Wound Team Protocol, section E. Documention" requires the following: "...documentation shall include: Staging (if appropriate) or partial or full thickness, drainage, color, odor depth, width, color of wound bed and surrounding tissue, location, and treatment...."

The Hospital policy titled, "Nursing Documentation-Patient's Medical Record" requires the following, "...Patient response and effectiveness or outcome of care: Evaluation will be documented through the patient problem list...."

Patient #4

Review of patient #4 medical record revealed that nursing staff failed to document wound characteristics and treatment for wounds on the leg and buttocks. The wound measurements, wound treatment and wound characteristics were not documented in the chart 11/20/17 to 11/30/17.

The RN Director of Medical Surgical and ICU #13 and RN House Supervisor #44 confirmed during interviews on 11/28/17 and 11/29/17, that nursing staff failed to document wound care.

Patient #12

Review of patient #12 medical record contained pictures of the open areas to the buttocks. A note from the Emergency Department Physician states the following: "...the pressure sore in the sacral region was cleaned and bandaged appropriately...." The wound measurements, wound characteristics and wound treatment were not documented in the medical record.

The RN Director of Regulatory Compliance #1, confirmed during an interview on 11/30/17, that nursing staff failed to document wound characteristics, measurements and treatment in the medical record.

Patient #16

Patient #16's medical record contained pictures of an open wound on the left leg. The wound measurements, characteristics and wound treatment was not documented in the medical record.

RN # 49 confirmed in an interview conducted on 11/27/17 and 11/28/17, that no wound care was being done. The wound was "open to air".

RN House Supervisor #44 confirmed in an interview conducted on 11/29/17, that the "wound care guide" was not followed when the wound was left "open to air".

Patient #28

Patient #28 medical record contained images of the arm wounds with a ruler placed next to the open area. Specific wound measurements, wound characteristics and wound treatment were not documented in the medical record. The documentation on 11/28/17 stated: "...laceration secured with steri-strips, covered with non-adherent telfa pad and wrapped with kerlix..."

RN House Supervisor #44 confirmed in a interview conducted on 11/29/17, that s/he assisted with the wound care. When asked what type of wound care was done, s/he replied, "...mepilex and kerlix were applied to the wound...the...." There was no documentation in the record related to this wound care. RN House Supervisor #44 confirmed: "...the nurse forgot to document the wound care...."

Based on review of hospital policy, documents, observations during tour, and staff interview, it was determined that the hospital failed to require the facility tested, maintained and verified equipment maintenance. This deficient practice posed the potential risk to patient safety if equipment failed to perform as the manufacturer intended.

Findings include:

The policy titled Scope of Service #PS-012 (effective 11/2015) requires: "...The policy applies to all facilities...All mechanical and electrical patient care equipment will be evaluated prior to use. Preventative maintenance schedules and safety inspections will be completed on all equipment, in the program. The results of inspections and maintenance will be kept in the preventative maintenance computer...All non-clinical electrically powered equipment will receive preventative maintenance...This equipment will also be safety inspected annually by the Plant Services Department...."

The facility provided no evidence of equipment testing/maintenance, as follows:

EMERGENCY DEPARTMENT:
Stryker electric beds (8)

OBSTETRICS DEPARTMENT:
Galley refrigerator (last PM "2014")
Secure electric bed OB Room (RM) #1
Phillips labor monitor (PM "due 05/2017")
Alaris Care Fusion IV pump (PM "due 08/2017")
Secure electric bed OB RM #6
Stryker electric labor/delivery bed RM D
Electric spot light (lamp)
Olympic electric baby scale RM C
Phillip labor monitor (PM "due 05/2017") RM C
Adel electric labor/delivery bed RM C
Sapphire Epidural pump (PM "due 04/2017") RM C
Adel electric labor/delivery bed RM B
Sapphire Epidural pump (PM "due 04/2017") RM A
Stryker electric bed
Phillips labor monitor (PM "due 05/2017") RM A

OUTPATIENT LABORATORY (PB):
General Electric (GE) refrigerator (last tested "12/014")
Ritter 204 electric exam table
Detecto patient scale

OUTPATIENT RADIOLOGY (PB):
Nanosonic Trofan High Level Disinfection (GE)
Lunar Prodigy Advance Dexiscan
Schiller Cardiovit MS-2015 EKG

SLEEP LAB (PB):
Easy-One Pro PF (pulmonary function)
Photic Stimulator - Neuroscan (last tested "10/04/15")

REHABILITATION SERVICES (PB):
Cardon Hi-Low Tables (2) indicated "PM due 06/2015"
Med-Ortho Hi-Low tables (5)
Chattanooga Hi-Low table
Woodway Treadmills (2)
Kolt Traction Table

Bio-Medical contractor #54 confirmed during interviews conducted on 11/28/17 and 11/29/17, no evidence of current equipment testing/maintenance for the above listed patient equipment.

Based on review of policy and procedure, medical record and interview, it was determined that the administrator failed to ensure that discharge planning identified the specific needs of the patient after discharge for 1 of 2 patients who were discharged with a non-surgical wound. This deficient practice posed a potential risk that the patient's needs would not be met upon discharge which could lead to further decline in the patient's health.

Findings include:

The hospital's "Patient Bill of Rights" requires the following: "...you can expect to be informed of a plan for follow up and ongoing care needs after discharge...."

Patient #12

Patient #12 was admitted on 11/24/17 and discharged on 11/28/17 for urinary tract infection (UTI) and leukocytosis. Review of the medical record on 11/29/17 revealed the following:

The Emergency Room report 11/24/17 revealed: "...stage II pressure ulcer towards midline on the left buttocks...pressure sore in the sacral region was cleaned and bandaged appropriately..."

History and Physical on 11/25/17 states: "...local wound care for stage II sacral decubitus. Discussed with RN...."

The Discharge Summary dated 11/28/2017 at 18:27 states: "...Skin: No skin breakdown seen or reported. No obvious rashes...."

The discharge packet in the patient's medical record contained the following: Current medications to discuss with your Primary Care Provider, Foley Catheter Placement and Care, Catheter-associated Urinary Tract Infection, and Urinary Tract Infection in Men.

RN Director of Regulatory Compliance #1 confirmed in an interview conducted on 11/30/17, that nursing staff failed to document wound care treatment and characteristics in the medical record. Discharge instructions were not given to the patient regarding wound care.

Based on review of hospital policies, Association of Surgical Technologists (AST) website, observations during tour, and staff interviews, it was determined that the hospital failed to require the staff sterilized and processed patient equipment according to policy. This deficient practice posed the risk of cross-contamination of infectious organisms between patients.

Findings include:

The hospital policy titled Surgical Instruments - Assemble and Packaging #SURG-052 (effective 04/2016) requires: "...Assemble and packaging instruments for reprocessing will be done according to AST (Association of Surgical Technologists) Standards of Practice and manufacturer's instructions...Assure all joints and hinges must be opened to ensure contact with the sterilizing agent. Instruments with detachable parts must be left disassembled...."

The Association of Surgical Technologist website ((www.ast.org), requires: "...Instruments with multiple parts usually should not be reassembled in order to make sure the sterilant contacts all surface areas ...The three principles that should be followed in the preparation of items to facilitate effective sterilization are: the sterilant comes into contact with all surface areas, instruments are positioned in a protective manner, and instruments are evenly distributed...Loose instruments, such as retractors, should not be tightly grouped together or wrapped. Instrument grouping and disproportionate metal contact inhibits the contact of the sterilant with all surface areas and may allow condensate to collect...."

The surveyor observed the following during tours conducted on 11/29/17:

OBSTETRICS DEPARTMENT and CENTRAL STERILE DEPARTMENT:

The hospital provides the infant Gomco circumcision clamp that consists of/requires assemble of 4 metal parts prior to use: base plate, "bell", rocker arm, and nut. The surveyor observed multiple (approximately 12) processed peel-packs, each containing (1) Gomco infant circumcision clamp with all 4 parts tightly assembled. This practice potentially does not allow steam to penetrate to all areas of the instrument to include the surgical/cutting edge.

Multiple peel-packs of clamps with the hinges closed and ratchets locked.

Multiple peel-packs containing multiple instruments such as a Haney retractor with (2) Allis tissue clamps, and Kelly clamps with scissors and tissue forceps. This nesting of multiple instruments in one peel-pack potentially does not allow steam to penetrate to all areas of the instruments.

Surgical Technician #25 confirmed during an interview conducted on 11/29/17, that surgical instruments should be packaged and processed so that all areas of the instruments are exposed to steam to ensure proper sterilization.