HospitalInspections.org

Based on observations, interviews and record reviews it was determined the facility failed to ensure nursing staff performed dressing changes in accordance with the facility policies and procedures during three of three observations of dressing changes on two patients (Patients #7 and #28).

Review of the facility's approved nursing reference manual revealed the procedure for the application of a "Dry and Moist-to-Dry Dressing" included that after a dirty dressing was removed from a patient the dressing should be discarded and the gloves removed. Hand hygiene should be performed and then clean gloves applied prior to applying the new dressing.

1. An observation made on 06/07/10 at 1:55 PM of a dressing change on Patient #7 revealed Registered Nurse (RN) #2 removed the dirty dressing from the coccyx. There was a moderate amount of yellow-red tinged drainage (as described by RN #2) on the dressing. The dirty dressing was discarded. Ointment was applied to the wound and a clean dressing applied. After the dressing change the patient was positioned in the bed. An additional observation made on 06/08/10 at 9:20 AM of a dressing change on Patient #7, which was performed by RN #1, revealed the dressing change was performed exactly as RN #2 had performed it on 06/07/10. RNs #1 and #2 did not change their gloves after removing the dirty dressing from Patient #7. The same gloves were worn throughout the entire procedure and while positioning and handling the linen of Patient #7.

2. An observation of Patient #28 on 06/07/10 beginning at 2:15 PM revealed RN #2 performed dressing changes to wounds to this patient's right sacral area, left sacral area and right lateral ankle. The dressing change for each area consisted of removing the old dressings and applying new gauze dressings soaked in Dakin's solution. The wet gauze was then covered in dry gauze and taped. The nurse was observed to remove the old dressing to each area and apply the new dressing without changing gloves or performing hand hygiene.

An interview with the Infection Prevention Nurse on 06/08/10 at 4:00 PM, revealed that once a dirty dressing was removed from a patient the dirty gloves should be discarded. Clean gloves should then be applied before applying the new clean dressing. She stated she did not observe nurses changing dressings on patients to determine if infection control standards were being maintained.

Based on observations, interviews, and record reviews, it was determined the facility failed to ensure medications were administered according to the facility's policies and procedures for three patients (#7, #8, and #15) in the selected sample of fourteen.

1. A review of the facility's approved nursing reference manual revealed the procedure for the administration of medication through a feeding tube included verifying placement of the feeding tube in the stomach prior to administering the medication.

Observations made on 06/08/10 at 8:45 AM revealed Registered Nurse #1 was administering medication to Patient #8 per the feeding tube. RN #1 removed the feeding tube cap, inserted a large syringe into the end of the feeding tube, and poured the medication into the large syringe. The medication was then administered through the feeding tube.

An additional observation made on 06/08/10 at 9:10 AM revealed Patient #7 received Norvasc 5 mg, Bactrim 400/80 mg, and Prevacid 30 mg/10 ml through his/her feeding tube. RN #1 removed the cap from the feeding tube, inserted a large syringe into the end of the feeding tube, and poured the medication into the large syringe. The medication was then administered through the feeding tube. After the medication was administered, it was then followed by water. The observations made revealed RN #1 did not verify that the feeding tube was in the stomach of Patients #7 or #8, just prior to the medications being administered.

2. Record review of Patient #7's medical record revealed a physician's order for the tube feeding to be administered at 60 cc and hour.

Observations on 06/08/10 at 9:30 AM and 10:40 AM revealed Patient #7's pump for the feeding tube was set at 55 cc per hour.

An interview with RN #1 on 06/08/10 at 10:25 AM revealed she had checked the placement of the feeding tubes on Patients #7 and #8 when she made her morning rounds at 7:30 AM. She stated that a feeding tube could become dislodged with the movements made by the patient and she should have checked the placement of the feeding tube just prior to administering the medications. Additionally, Patient #7's tube feeding was suppose to be set at 60 cc per hour but she failed to notice the error.

3. Review of the facility policy titled "Administration of Medications" revealed that a medication that was ordered to be administered "Now" should be administered within one hour or less.

Review of the medical record of Patient #15 revealed a physician's order written on 06/05/10 at 1:00 PM for "Tylenol 650 mg po (by mouth) now." Review of the medication administration record revealed the Tylenol was administered on 06/05/10 at 4:00 PM.

An interview with the Director of Patient Services on 06/08/10 at 10:45 AM revealed the nurse should check for placement of the feeding tube just before the medication was administered. It was not acceptable to verify placement of the feeding tube one to two hours before the medication was going to be administered. She stated "now" ordered medications should be administered within one hour.