HospitalInspections.org

Based on observation and staff interviews, it was determined that the facility failed to provide personal privacy for each patient.

Findings include:

1. On 10/23/18 during a tour of the facility, the following units hada white board which contained patient information. The board was hanging on the wall at the nurse's station and had the patient's first and last names written next to their room numbers:

a. Critical Care Unit, CC1

i. The white board could be visualized from the counter at the nurse's station.

b. Medical-Surgical Unit, 2 West

ii. Two (2) patient rooms, each containing a window, were connected to the nurse's station and were in direct view of the patient information written on the white board.

2. The above findings were confirmed by Staff #2, Staff #3, Staff #4 and Staff #5.

Based on medical record review and staff interview, it was determined that the facility failed to ensure all patient's nursing care needs are accurately assessed, to develop an appropriate nursing care plan in response to identified nursing care needs.

Findings include:

1. Review of Medical Record #1 indicated the following:

a. Nursing note written by Staff #18, dated 7/24/18 at 0900, "Stage 1-2 breakdown noted on L [left] buttock no c/o [complaint of pain]..."

2. Medical Record #1 lacked evidence of a care plan based on the patient's nursing care needs of Stage 1-2 breakdown.

3. Upon interview, Staff #5 confirmed that Medical Record #1 lacked documented evidence of interventions for the Stage 1-2 skin breakdown.

Based on medical record review and staff interview, it was determined that the facility failed to ensure all medical records accurately and completely include all assessments, care plans and interventions.

Findings include:

1. Review of Medical Record #1 indicated the following:

a. Nursing note written by Staff #18, dated 7/24/18 at 0900; "Stage 1-2 breakdown noted on L [left] buttock no c/o [complaint of pain]..."

b. Nursing note written by Staff #18, dated 7/24/18 at 1300; "Pericare given w/triple paste applied to b/l [bilateral] excoriated buttocks."

c. Nursing note written by a Staff #20, dated 7/24/18 at 1853 indicated, "pt [patient] bottom excoriated barrier cream applied [sic]."

d. The Universal Transform Form dated 7/30/18; "back abrasion, sacrum excoriated."

2. The assessment made on 7/24/18 at 0900 is inconsistent with all other documented assessments.

3. Upon interview, Staff #5 stated that the nurse's note dated 7/24/18 at 0900, documented by Staff #18; an agency nurse, was inconsistent with all the other nursing assessments. Furthermore, the patient never had Stage 1-2 breakdown as indicated in all subsequent nursing assessments.

Based on observation, medical record review, staff interviews, review of facility signage and policy and procedure, it was determined that the facility failed to ensure implementation of infection prevention.

Findings include:

Reference #1: Facility policy, Guideline For Isolation Precautions, states, "...Visitors of Patients in Isolation. Visitors desiring to see patients in isolation will be requested to adhere to isolation protocol as listed and observe the following procedures prior to entering the patient's room: Follow precautions per the isolation sign ... Contact Isolation Precautions Require: ... 2. Gloves and gowns must be worn to enter the patient's room."

1. During a tour of the Progressive Care Unit (PCU), on 10/23/18, in the presence of Staff #2, Staff #3 and Staff #4, the following was observed:

a. At 11:36 AM, two staff members were in Room #1108, a contact isolation precaution room, with contact isolation signage.

i. Patient #11 was diagnosed with Vancomycin Resistant Enterococci (VRE) in the urine.

ii. Staff #15 and Staff #16 were cleaning the patient and his/her bedding.

iii. Staff #16's gown was untied and the ties were touching the bedding.

iv. Another staff member was observed standing outside the patient's room, handing patient linens to Staff #15, who was gowned and in the patient's room, then opened the trash can that is inside the patient's room with ungloved hands to dispose of wrapping from the patient linen.

Reference #2: Facility isolation sign states, "Contact Precautions, STOP, Visitors: Please report to the Nurse's Station before entering the patient room. Gloves must be worn to enter. Gowns must be worn to enter... ."

1. During a tour of the following units, on 10/23/18, in the presence of Staff #2, Staff #3, Staff #4 and Staff #5, the following was observed:

a. At 12:00 PM on the 2 West unit, in the presence of a Staff #2, Staff #3, Staff #4 and Staff #5, Patient Room #203 had signage posted outside the door which indicated the patient is on Contact Isolation Precautions.

i. Patient #6 was diagnosed with Methicillin Resistant Staphylococcus Aureus (MRSA).

ii. Patient #6 had visitors in the room. The visitors were not wearing gowns or gloves.

2. At 12:31 PM on the 2 West Unit, an interview was conducted with Staff #17. He/she explained that family members visiting a patient who is on Isolation Precautions will receive education on hand hygiene and PPE prior to entering the patient's room. He/she stated that the education performed should be documented in the patient's medical record, under nursing shift assessment, in the education section.

a. On 10/24/18 medical record review of two (2) of two (2) contact isolation patients (Medical Record # and Medical Record #11), lacked documented evidence of the patient or the patient's family receiving education regarding isolation precautions.

3. The above finding was confirmed by Staff #4.