HospitalInspections.org

Based on medical record (MR) reviews, policy and procedures, wound care protocols, observation, and interviews, it was determined staff failed to:

1. Perform and document patient/caregiver education

2. Notify the physician of changes in a patient's condition

3. Document wound care protocol on the physician's orders.

This affected medical records # 2, # 10, # 11, and # 13; 4 of 4 patients with wounds and had the potential to negatively affect all patients served by this facility.

Findings include:

Agency Policy:
Title: Pressure Ulcer Treatment/Alteration of Skin Integrity Treatment
Date Reviewed/Revised: 1/14

Patients will be assessed on admission, by an RN (Registered Nurse), and daily by a licensed nurse, for wounds caused by pressure, friction, shear, moisture, and/or skin tears. If such a wound is found the nurse will implement appropriate wound management strategies to optimize the healing potential and document in the patient's medical record at a minimum and as applicable:
" *The stage of the wound following the National Pressure Ulcer...
*Location;
*Describe tissue type and/or wound bed (granulation), ...
*Size including length, width, and depth in centimeters;
*Presence and location of tunneling and/or undermining;
*Describe exudate/drainage (odor, color, type and/or character);
*Describe surrounding tissue (intact, erythema, warmth, etc.)

Management of wounds requires a multidisciplinary approach and may involve, but not be limited to, the patient/family, physician, nurse, physical therapist, dietician, and/or wound nurse/consultant.

Procedure:
An RN will perform assessment of the patient on admission....
Upon discovering a pressure related wound, a photograph of the wound will be taken according to the wound photography policy and documented in the patient's medical record."


Wound Care Protocol- effective date 10/4/2011
Procedure:
"Skin Tear:
1. Cleanse with Skintegrity. Gently pat dry.
2. Periwound- none.
3. Primary dressing- cover with Optifoam Gentle dressing.
4. Secondary dressing- none
5. Change dressing every 3 days and prn (as needed)."


Title: Patient Assessment
Date Reviewed/Revised: 3/13

Policy: Qualified and trained personnel will continuously assess all patient care needs from the point of initial patient contact throughout their hospitalization, utilizing standardized written assessment tools. A registered nurse is responsible for assessing the patient's needs and/or verifying LPN (Licensed Practical Nurse) assessment for nursing care in all areas where nursing care is provided and establishing the nursing diagnosis. The initial assessment will identify immediate and developing needs of the patient and subsequent assessments will identify changing needs depending on how the patient responds to care and treatment.

"Assessments will be age specific and individualized...
Significant changes in assessment are reported to the attending physician (i.e. pain unrelieved, vital signs, wounds, surgical sites, etc.)"



1. MR # 11 was admitted on 6/30/14 with diagnoses including Urinary Tract Infection (UTI) and Altered Mental Status (Improved).

Review of the physicians admission orders for MR # 11 on 6/30/14 revealed no wound care or mention of a wound to the buttocks.

During a tour of the medical unit was conducted on 7/1/14 at 1:00 PM the surveyor requested to observe wound care. MR # 11 was identified to have a "bad" wound per staff.

An observation of the physician's wound assessment conducted on 7/2/14 at 8:45 AM revealed MR # 11 had a total of 4 Stage IV (4) pressure ulcers on buttocks which now required surgical intervention.

Review of the nursing admission assessment dated 6/30/14 at 4:00 PM revealed there was no documentation of the patient's wounds. The nursing staff failed to implement appropriate wound management strategies to optimize the healing potential.

An interview was conducted on 7/3/14 at 9:42 AM with Employee Identifier (EI) # 1, the CCO/CNO, (Chief Clinical Officer/Chief Nursing Officer) confirmed the nursing staff failed to follow wound care protocols.


2. MR # 2 was admitted 3/1/14 with diagnoses including Debility NOS (Not Otherwise Specified).

Review of the MR revealed documentation on 3/2/14 at 1:19 PM the location of IV (intravenous) was changed from the left wrist to the right hand. There was no documentation of any complications with the left hand site or the nursing interventions used to change the site to right hand.

Further documentation revealed on 3/3/14 at 9:28 PM the location of IV as left AC (antecubital). There was no documentation of any complications with the right hand IV site or the nursing interventions used to change the site to the left AC.

The patient was assessed to have a Stage II (2) Pressure Ulcer to the right inner ankle. There were documented changes in the size of the wound, color and odor of drainage on 3/4/14, 3/5/14, 3/8/14, 3/11/14, 3/14/14, and 3/17/14. There was no documentation the physician was notified of any of the changes in wound size, color and odor of drainage on the aforementioned dates.

There was no documentation the nursing staff had provided the patient/caregiver any education of the signs and symptoms of infection or how to prevent pressure ulcers from admission date of 3/1/14 to discharge on 3/21/14.


An interview was conducted on 7/3/14 at 9:30 AM with Employee Identifier (EI) # 1, the CCO/CNO verified the above findings.



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3. MR # 10 was admitted to the swing bed unit 6/18/14 with diagnoses of Fracture Left Tibia, Debility and Right Breast Carcinoma, Status Post Lumpectomy and Diabetes Mellitus insulin dependent.

The nursing assessment dated 6/18/14 documented, "Pt (patient) has staples on lower right breast. Were due to come out but fall prevented."

The nurse failed to document the length of the incision, the number of staples present or if a dressing was present.

The nurse documented 6/19/14, "Pt has 13 staples to the right breast..."

The patient returned to surgery 6/20/14 for a lumpectomy of the right breast. The nurse documented, "Surgical wound to left breast, covered with clean dressing, no drainage or discharge present..."

The nurse documented the wound to the wrong breast.

New orders received 6/24/14 for wound care to right breast,"Clean with soap and water every day and dress with gauze."

The nurses continued to provide wound care to the right breast but failed to measure the area from 6/20/14 through the review 7/2/14.

In an interview 7/3/14 at 9:35 AM with EI # 1, the above information was confirmed.


4. MR # 13 was admitted to the swing bed unit 6/11/14 with diagnoses of Debility, Congestive Heart Failure and Severe Chronic Obstructive Pulmonary Disease.

The physician's orders on transfer to the swing bed unit included: Skin tear protocol to LFA (left forearm) x 2.

The initial assessment completed 6/11/14 documented, " Multiple skin tears to left and right arm, cleaned and covered with optifoam."

The nurse failed to document what she cleaned the skin tears with, how many areas were dressed and failed to measure the areas.

The nurse documented 6/12/14 and 6/13/14 skin tears right and left arm covered with optifoam.

Wound care was documented 6/15/14,"Cleaned with Skintegrity and sureprep around wound edges, optifoam dressing applied, small amount of drainage noted."

The nurse failed to document appearance of drainage, wound beds, or odor. The areas were not measured.

On 6/19/14 wound care was documented to the right elbow and right forearm, " Removed old dressing, cleaned with Skintegrity and sureprep around wound edges, optifoam dressing applied."

There was no documentation of the left arm healing or how/ when the patient injured his right elbow.

On 6/22/14, 6/23/14, 6/24/14, 6/25/14, 6/26/14, wound care was documented to the right elbow, " Cleaned with Skintegrity and sureprep around wound edges, optifoam dressing applied."

There was no documentation or reason the nurse started doing wound care daily to the elbow and no documentation regarding the right forearm.

On 6/29/14 the patient staggered into the doorframe causing one skin tear on the left elbow and two on the left forearm. Treated per wound care protocol, " Cleaned with Skintegrity and sureprep around wound edges, optifoam dressing applied."

On 6/30/14 wound care was documented to the left forearm and elbow.

The wound care protocol was never transferred to the order form as required. The different wounds were not identified with orders to be followed for the different area and no description of the areas, drainage, odor or size was documented.

In an interview 7/3/14 at 10:00 AM with EI # 1, it was confirmed that to use the protocols an order must be documented. EI # 1 confirmed the nurses failed to follow wound care protocols and document wound appearance and locations.

Based on observation, CDC (Centers for Disease Control) safe practices for use of multi-dose vials, policy and procedures and interview with facility staff it was determined the facility failed to ensure all medications and biological's available for patients were not expired. The facility failed to ensure all multi-dose vials and solutions were labeled with the date opened. This had the potential to affect all patients served by this facility.

Findings include:

Policy: Infection Control (There was no date the policy was written or revised on the form.)

The Nursing Services Department recognizes the impact and responsibility of carrying out the practical aspects of infection control, as nurses are the only persons throughout the hospital who have direct contact with the patient's 24-hours a day.

Medications/Intravenous (IV) Fluids:

"All parenteral and IV medications must be prepared using strict aseptic technique. Disinfect the counter area with an approved disinfectant prior to medication/IV solution preparation.

Multidose vials will be used for the treatment of a single patient.

Multidose vials are to be dated when opened, stored appropriately and disposed of in 28 days or per manufacturer's expiration date and/or pharmacy recommendations..."

CDC- Multi-dose vials- Safe Practices last updated 2/9/11

Questions about multi-dose vials:

4. When should multi-dose vials be discarded?

Medication vials should always be discarded whenever sterility is compromised or questionable.

In addition, the United States Pharmacopoeia (USP) General Chapter 797[16] recommends the following for multi-dose vials of sterile pharmaceuticals:

1. If a multi-dose has been opened or accessed (needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.


During a tour of the Emergency Department on 7/1/14 at 8:30 AM the surveyor observed in room # 6 the following opened 1000 cc (cubic centimeters) bottles of Normal Saline which were not labeled as to the date they were opened:

Bottle # 1 of Normal Saline with 30 cc of liquid in the bottom.

Bottle # 2 of Normal saline with 400 cc's of liquid.

Bottle # 3 of Normal saline with 400 cc's of liquid.

Employee Identifier # 9, the Emergency Room Director, confirmed 7/1/14 at 9:30 AM the bottles should have been dated when opened and discarded all three bottles.


A tour of the Pharmacy Department was conducted on 7/1/14 at 1:15 PM with EI # 6, Pharmacist. The surveyor observed the following opened and unlabeled medications.

Folic Acid 5 milligram (mg)/ milliliter (ml), a 10 ml vial.
Vancomycin 1 Gram per 20 ml vial.
Erythromycin 500 mg/5 ml 10 ml vial.
Sodium Bicarbonate 10 grain tablets 200 count container.
Isosorbide Dinitrate 20 mg tablets 200 count container.
Decadrol Elixir 0.5 mg/5 ml 500 ml container.
Prednisolone Oral Solution 15 mg/5 ml 100 ml container.
Phenobarbital Elixir 500 ml container.

The aforementioned vials were open with no date the vials or bottles were first accessed. These were verified at the time of the tour with EI # 6, Pharmacist.


1. MR # 11 was admitted on 6/30/14 with diagnoses including Urinary Tract Infection (UTI) and Altered Mental Status (Improved).

Observation was made on 7/2/14 at 12:45 PM of the SN (skilled nurse) providing wound care. The following opened medications were observed in the patient's room: Triamcinolone Acetonide 0.1% cream; Santyl Ointment and wound cleanser 12 oz bottle. These medications were not labeled with the date they were open as directed per the facility policy.

An interview was conducted on 7/3/14 at 9:42 AM with EI # 1, the CCO/CNO, (Chief Clinical Officer/Chief Nursing Officer) who verified the nursing staff did not follow the policy for labeling open medications/containers.

Based on United States Health Public Food Code 2009 regulations, observations and interview, it was determined the facility failed to ensure food was stored in a safe and sanitary manner.

This had the potential to negatively affect all patients.

Findings include:

United States Health Public Food Code 2009

3-501.17 Ready-to-Eat, Potentially Hazardous Food
(Time/Temperature Control for Safety Food),
Date Marking.
...commercially processed food open and hold cold
(B) Except as specified in (D) - (F) of this section, refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety...

(C) A refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) ingredient or a portion of a refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is subsequently combined with additional ingredients or portions of food shall retain the date marking of the earliest- prepared or first prepared ingredient.

(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include:...
(2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section;
(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section...


During a tour of the Dietary Department on 7/1/14 at 11:30 AM with Employee Identifier (EI) # 5, Dietary Manager the surveyor observed opened food containers with no dates, food items which had expired and inappropriately stored food items.

Located in the cooler were the following inappropriately stored food items which were opened with no date or expired items.

A package of processed ham loosely wrapped in clear plastic wrap with no date the package was opened.
A package of lettuce loosely wrapped in clear plastic wrap with no date the package was opened.
Cheese slices loosely wrapped with clear plastic wrap labeled with the date of 5/30/14.

Located in the dry storage area were the following inappropriately stored food items which were opened with no date:

An 18 oz (ounce) package of baking soda.
3 16 oz bottles of food coloring.
A 16 oz bottle of vanilla flavoring.
A 16 oz bottle of butter flavoring.

Located in the kitchen was a 32 oz opened bag of french fried onions with no date on the bag.

An interview was conducted on 7/1/14 at 11:55 AM with EI # 5, who confirmed the items listed above were expired, inappropriately stored and were opened and not dated.

Based on review of personnel files and interviews revealed the facility failed to ensure the Dietary Manager had been provided the training/competency required to function in this new position. This affected 1 of 2 dietary personnel files and had the potential to negatively affect all patients served by this facility.

Findings include:

Review of Employee Identifier (EI) # 5, Dietary Manager personnel file was conducted on 7/3/14 at 8:20 AM. There was no record of orientation or training/competency documented since EI # 5's position changed in April 2014.

An interview was conducted on 7/3/14 at 9:20 AM with Employee Identifier (EI) #1, CCO/CNO (Chief Clinical Officer/Chief Nursing Officer) who verified the aforementioned findings.

Based on observation and interview it was determined the facility failed to have a current therapeutic Diet Manual. This had the potential to negatively affect all patients served by this facility.

A review of the current diet manual on 7/1/14 at 3:30 PM revealed the diet manual was last updated on 10/15/07.

An interview was conducted on 7/1/14 at 4:45 PM with Employee Identifier # 8, RD (Registered Dietitian) it was verified the facility diet manuals had not been updated since 2007.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to affect all patients served.

Findings include:

Refer to Life Safety Code violations.

Refer to A 701 for additional findings.

Based on observation and interview it was determined the facility failed to maintain and keep equipment in working order. This had the potential to negatively affect all patients, staff and visitors served by the facility.

Findings include:

A tour of the dietary department was conducted on 7/1/14 at 11:00 AM with Employee Identifier (EI) # 5, the Dietary Manager and EI # 7, (Dietary Director). The dishwasher was found to be out of order. Staff was questioned as to how long it had not been functioning. "It was reported broken to maintenance the Friday before last." (6/20/14). The dietary staff had been using disposable items since that date.

An interview was conducted on 7/3/14 at 9:20 AM with EI # 1, CCO/CNO (Chief Clinical Officer/Chief Nursing Officer). The above findings were confirmed along with information that conflict resolution had been made between departments, parts ordered and the repair work had begun on 7/3/14.

Based on review of the Daily Crash Carts Checklists in the Emergency Department, observations and interviews with staff, it was determined the nursing staff failed to ensure the emergency carts were equipped and ready for use in an emergency. This had the potential to negatively affect all patients admitted to this facility.

Findings include:

During a tour of the Emergency Department room # 4, 7/1/14 at 8:30 AM the surveyor observed the Daily Crash Cart Checklist attached to the Crash Cart for the month of June 2014.

The Crash Cart Checklist includes the following items are to be checked daily:
Cart fully stocked
Unplugged defibrillator test
Defibrillator pads are unexpired
Bag and mask
Suction canister and tubing
Date of first expired drug
O2 (oxygen) tank pressure
Back Board
Lock number and initials of the staff member performing the checklist.

The cart was not checked 6/4/14, 6/9/14, 6/12/14, 6/13/14, 6/15/14, 6/16/14, 6/17/14, 6/18/14, 6/19/14, 6/20/14, 6/21/14, 6/23/14, 6/24/14, 6/25/14, 6/26/14, 6/29/14 and 6/30/14.

During a tour of the Emergency Department hallway, 7/1/14 at 9:15 AM the surveyor observed attached to Crash cart the Daily Crash Cart Checklist for the month of May and June 2014.

The cart was not checked 5/7/14, 5/8/14, 5/9/14, 5/10/14, 5/12/14, 5/13/14, 5/14/14, 5/15/14, 5/18/14, 5/19/14, 5/20/14, 5/21/14, 5/22/14, 5/23/14, 5/24/14, 5/25/14, 5/26/14, 5/27/14, 5/30/14 and 5/31/14.

The cart was not checked 6/3/14, 6/4/14, 6/9/14, 6/12/14, 6/13/14, 6/15/14, 6/16/14, 6/17/14, 6/18/14, 6/20/14, 6/21/14, 6/23/14, 6/26/14 and 6/27/14.

In an interview 7/1/14 at 9:30 AM with Employee Identifier # 9, the Emergency Room Director, confirmed the form was not completed daily.

Based on observations, CDC guidelines for hand hygiene in health care settings, and interview it was determined the facility staff failed to:

1. Maintain and clean equipment to prevent potential infection to patients and/or staff by use.

2. Perform hand hygiene after removing soiled gloves and reapplying clean gloves.

This had the potential to affect all patients served by this facility and did affect Medical Record (MR) # 11.

Findings include:

www.cdc.gov
Morbidity and Mortality Weekly Report
Recommendations and Reports October 25, 2002 / Vol. 51 / No. RR-16
Centers for Disease Control and Prevention

Guideline for Hand Hygiene in Health-Care Settings
Recommendations for Hand Hygiene

"...C. Decontaminate hands before having direct contact with patients
F. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, lifting a patient)
I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient
J. Decontaminate hands after removing gloves..."


1. MR # 11 was admitted on 6/30/14 with diagnoses including Urinary Tract Infection (UTI) and Altered Mental Status (Improved).

An observation was made on 7/2/14 at 12:45 PM with Employee Identifier (EI) # 10, RN to perform wound care. EI # 10 failed to perform hand hygiene before initiating wound care or between glove changes.

An interview was conducted on 7/3/14 at 9:42 AM with EI # 1, the CCO/CNO, (Chief Clinical Officer/Chief Nursing Officer) and the aforementioned findings were verified that the hand hygiene policy had not been followed.

Based on review of medical records and interview it was determined the facility failed to:

1. Document a choice/ list of home health agencies being offered to patients/ caregivers referred for home health services.


This had the potential to affect all patients referred for care after discharge and did affect Medical Record (MR) # 9 and # 13, 2 of 2 patients referred for home health services.



Findings include:

1. MR # 13 was admitted to the swing bed unit 6/11/14 with diagnoses of Debility, Congestive Heart Failure and Severe Chronic Obstructive Pulmonary Disease.

A review of the discharge planning information failed to document a choice form home health agencies presented to the patient.

The patient information and choice letter completed 6/30/14 documented, " Home Health Services: I prefer to use..."

There was no documentation of how the patient came to choose this agency.


2. MR # 9 was admitted to the facility 4/14/14 with diagnoses of Cholelithiasis, Pleural Effusion, Diabetes Mellitus Type II, Anemia and Hypertension.

A review of the discharge planning information included the option to discharge home with home health.

The Discharge Disposition Form dated 4/18/14 documented, " Referral to ..."

There was no choice form in the record and no documentation of how that particular agency was chosen for the patient.

A review of the discharge planning information failed to document a choice form home health agencies presented to the patient.

In an interview 7/3/14 at 10:00 AM with Employee Identifier (EI) # 1, the Chief Clinical Officer/Chief Nursing Officer, the above information was confirmed.

Based on interview and review of swing bed records the hospital failed to assure activities were provided to swing bed patients to meet their interests and for the well-being of the patients. This affected Medical Record (MR) # 2, # 10 and # 13, 3 of 3 patients on the swing bed unit and had the potential to affect all patients served in the swing bed unit.

Findings include:


1. MR # 2 was admitted to the swing bed unit 3/1/14 with diagnoses including Debility NOS (Not Otherwise Specified).

The Initial Activity Assessment was completed 3/6/14 at 3:00 PM.

The assessment form documented Preferred Treatment Modalities:
Validation Therapy
Sensory Stimulation
Increased Physical Functioning
Isolation Reduction.

Initial Treatment Plan (Focus of treatment)
AT (activity) will encourage participation in activities 5 x week (5 times per week) in order to increase motivation, socialization and physical functioning.

The documentation on the activity offered form documented Television as the activity of choice 3/9/14, 3/10/14, 3/11/14, 3/12/14, 3/13/14, 3/14/14, 3/15/14, 3/16/14, 3/17/14, 3/20/14 and 3/21/14.

The swing bed staff failed to offered any interactive activities or participate in an activity with the patient.


2. MR # 10 was admitted to the swing bed unit 6/18/14 with diagnoses of Fracture Left Tibia, Debility and Right Breast Carcinoma, Status Post Lumpectomy and Diabetes Mellitus insulin dependent.

The Initial Activity Assessment was completed 6/23/14 at 3:00 PM documented,"Pt. (patient) visiting with family and unable to obtain assessment at this time. Introduced self to pt and family and informed will return at a later time to complete assessment."

The assessment form documented Preferred Treatment Modalities:
Validation Therapy
Sensory Stimulation
Increased Physical Functioning
Isolation Reduction.

Initial Treatment Plan (Focus of treatment)
AT (activity) will encourage participation in activities 5 x week in order to increase motivation, socialization and physical functioning.

The Patient (pt) Assessment Report documented Activity Offered:
6/24/14 - 9:26 AM Television (TV), book, narrative- pt listening to TV
6/25/14 - 9:21 AM Television (TV), narrative- pt resting in gerichair watching TV
6/25/14 - 5:22 PM Television (TV) book, magazine, narrative- pt up to chair watching TV.

The documentation on the activity offered form continued to document Television as the activity of choice 6/27/14, 6/28/14, 6/29/14, 6/30/14 and 7/1/14.

The swing bed staff failed to offered any interactive activities or participate in an activity with the patient.

There was no documentation of another attempt to visit the patient to determine any interest or establish specific interventions for the patient to participate in as activities.

3. MR # 13 was admitted to the swing bed unit 6/11/14 with diagnoses of Debility, Congestive Heart Failure and Severe Chronic Obstructive Pulmonary Disease.

The Initial Activity Assessment was completed 6/13/14 at 3:00 PM documented, " Pt. states he used to paint but no longer does."

The assessment form documented Preferred Treatment Modalities:
Validation Therapy
Sensory Stimulation
Increased Physical Functioning
Isolation Reduction.

Initial Treatment Plan (Focus of treatment)
AT (activity) will encourage participation in activities 5 x week in order to increase motivation, socialization and physical functioning.


The documentation on the activity offered form continued to document Television as the activity of choice 6/12/14, 6/17/14, 6/18/14, 6/19/14, 6/20/14, 6/21/14, 6/22/14, 6/23/14, 6/24/14, 6/25/14, 6/26/14, 6/27/14, 6/29/14, 6/30/14 and 7/1/14.

The swing bed staff failed to offered any interactive activities or participate in an activity with the patient.

In an interview 7/3/14 at 10:00 AM with Employee Identifier # 1, the Chief Clinical Officer/Chief Nursing Officer, confirmed the staff failed to document other activities offered or participated in with the patients.