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Based on record review and staff interview it was determined the facility failed to ensure an adequate number of nursing personnel was available to ensure the needs of the patients were met for 3 (#1, #4, #5) of 5 patients sampled. This practice does not ensure the patients goals are achieved.

Findings include:

1. Interview with a staff nurse on 3/08/10 at approximately 11:45 a.m. revealed the staff member stated s/he felt there was not enough Patient Care Technicians (PCT) to assist with the turning and repositioning of patients. Interview with a PCT on 3/08/10 at approximately 12:15 p.m. revealed the technician stated s/he was not always able to turn the patients every two hours.

2. The facility's policy "Wound Prevention" # H WC 01-001 dated 2/07 requires that patient's be turned every two hours if patient is unable to reposition self

Patient # 1 was admitted to the facility on 2/3/09. Review of photographs in the medical record and interview with the wound care nurse on 3/8/10 at approximately 12:30 p.m. revealed that the patient had no pressure ulcers at the time of admission. On 5/16/09 the wound care nurse noted the patient had a stage III pressure ulcer on the coccyx area. The patient's plan of care required that the patient was to be turned every 2 hours. Documentation of the patient's repositioning was reviewed form 3/19/09 to 5/10/09. The following non compliance with the plan of care for turning was noted
on 3/24/09, 3/30/09, 3/31/09, 4/1/09, 4/6/09, 4/8/09, 4/20/09, 4/24/09, 5/1/09, and 5/6/09.
The Chief Clinical Officer confirmed the above during interview on 3/8/09 at approximately 1:00 p.m.

3. Patient #4 was admitted to the facility on 2/26/09. Nursing admission documenting revealed the patient had no pressure ulcer at the time of admission. Review of nursing documentation revealed a stage I pressure ulcer was discovered on the patient's left heel. Review of the patient's medical record revealed the following noncompliance with requirement to turn the patient every 2 hours on 2/28/10, 3/04/10, and 3/06/10. The above findings were confirmed during interview with the Infection Control practitioner on 3/7/09 at approximately 9:50 a.m.
4 Patient #5 was admitted to the facility on 2/22/10. Nursing documentation revealed the presence of pressure ulcers of the coccyx and bilateral ankles. Review of the patient's medical record revealed the following noncompliance with requirement to turn the patient every 2 hours on 2/24/10, 2/25/10, 3/01/10, 3/05/10, and 3/06/10. The above findings were confirmed during interview with the Infection Control Practitioner on 3/7/09 at approximately 2:58 p.m.

Based on record review, policy review and staff interview, it was determined that the Registered Nurse failed to supervise and evaluate the needs of the patient for 3 (#1,#4,#5) of 5 sampled patients. This practice does not ensure patient goals are achieved.

Findings include:

1. The facility's policy "Wound Prevention" # H WC 01-001 dated 2/07 requires that patient's be turned every two hours if patient is unable to reposition self

Patient # 1 was admitted to the facility on 2/3/09. Review of photographs in the medical record and interview with the wound care nurse on 3/8/10 at approximately 12:30 p.m. revealed that the patient had no pressure ulcers at the time of admission. On 5/16/09 the wound care nurse noted the patient had a stage III pressure ulcer on the coccyx area. The wound care nurse documentation stated the pressure ulcer progressed to a stage IV wound during the hospital stay.

The patient's plan of care required that the patient was to be turned every 2 hours. Documentation of the patient's repositioning was reviewed form 3/19/09 - 5/10/09. The following non compliance with the plan of care was noted:
On 3/24/09 the patient was not repositioned from 3:10 p.m. to 8:00 p.m.
On 3/30/09 the patient was not repositioned form 12:00 noon to 4:10 p.m.
On 3/31/09 the patient was not repositioned from 4:00 a.m. to 8:00 a.m.
On 4/1/09 the patient was not repositioned from 2:00 a.m. to 6:00 a.m.
On 4/6/09 the patient was not repositioned from 8:00 p.m. to 11:04 p.m.
On 4/8/09 the patient was not repositioned from 8:00 a.m. to 12:00 noon
On 4/20/09 the patient was not repositioned from 4:00 p.m. to 8:00 p.m.
On 4/24/09 the patient was not repositioned from 12:24 p.m. to 5:00 p.m.
On 5/1/09 the patient was not repositioned from 9:30 a.m. to 2:40 p.m.
On 5/6/09 the patient was not repositioned from 2:00 p.m. to 8:00 p.m.
The Chief Clinical Officer confirmed the above during interview on 3/8/09 at approximately 1:00 p.m.

2. Patient #4 was admitted to the facility on 2/26/09. Nursing admission documenting revealed the patient had no pressure ulcer at the time of admission. Review of nursing documentation revealed a stage I pressure ulcer was discovered on the patient's left heel. Review of the patient's medical record revealed the following noncompliance with requirement to turn the patient every 2 hours:
On 2/28/10 at 6:02 a.m. the patient was supine. At 8:00 a.m. and 10:00 a.m. the patient refused to be turned. The notes noted the patient was supine at 12:00 p.m. and turned to left side at 2:00 p.m. There was no evidence of the patient refusing to be turned at 12:00 p.m.
On 3/04/10 the patient was not repositioned from 11:00 a.m. to 2:00 p.m.
On 3/06/10 the patient was not repositioned from 6:00 a.m. to 4:00 p.m.
The above findings were confirmed during interview with the Infection Control practitioner on 3/7/09 at approximately 9:50 a.m.
3. Patient #5 was admitted to the facility on 2/22/10. Nursing documentation revealed the presence of pressure ulcers of the coccyx and bilateral ankles. Review of the patient's medical record revealed the following noncompliance with requirement to turn the patient every 2 hours:
On 2/24/10 the patient was in the supine position from 6:00 a.m. to 10:00 a.m. The patient on the right side from 4:00 p.m. to 8:00 p.m.
On 2/25/10 the patient was not repositioned from 2:00 a.m. to 6:00 a.m.
On 3/01/10 the patient was not repositioned from midnight to 6:00 a.m. The patient was not repositioned from 6:00 a.m. to 10:00 a.m. and from 4:00 p.m. to 8:00 p.m.
On 3/05/10 the patient was supine at midnight and not repositioned until 4:00 a.m.
On 3/06/10 the patient was not repositioned from 8:00 p.m. to 2:00 a.m.
The above findings were confirmed during interview with the Infection Control Practitioner on 3/7/09 at approximately 2:58 p.m.

Based on observations and policy review, it was determined that the facility failed to ensure that measures were implemented to prevent the spread of infection. This practice does not ensure patient safety.

Findings include:

1. During observation of a dialysis procedure for patient #2 at 8:45 a.m. on 3/8/10, dirty linen was noted on the floor by a trash can and biohazard red trash can was overflowing contaminated trash onto the floor.

2. During observation on the 2N unit of the hallway on 3/8/10 at approximately 10:00 a.m. a Licensed Practical Nurse was observed taking a rolling blood pressure and temperature machine into patient room with a posted contact precaution sign. The machine was used to assess patient's vital signs and then rolled back out into hallway without sanitizing machine.

3. During observation in hallway of the 2N unit from approximately 10:30 a.m. to 11:00 a.m., a housekeeping staff member was observed to go in and out of patient rooms with posted contact precaution signs, without changing protective gown between rooms.

4. During observation at approximately 10:45 a.m. on 03/08/10 in the hallway of 2N unit, x-ray technicians were observed entering room 251, where a contact precautions sign was posted. The x-ray technicians did not wear protective gowns. The Registered Nurse verified the patient was in isolation.

5. During observation on 2N unit on 3/8/10 at approximately 1:00 p.m. a housekeeper was observed in patient rooms with posted contact precaution signs. The employee was observed to be taking trash out of the patient rooms and was not wearing protective gown or gloves.

6. During the initial tour on 3/7/10 at approximately 8:30 a.m., a housekeeping staff person was observed in room #260. A contact isolation sign was posted for the patient in the room. The staff person was not wearing a protective gown or gloves. The staff member left room the room, leaving the mop in the bucket and went to room #259. There was no isolation sign posted for that patient. The housekeeping staff person left the room, carrying a bag of trash. The staff person was not wearing gloves. The Infection Control Practitioner was interviewed on 3/8/10 at approximately 1:00 p.m. She stated that the employee should have been following facility policy, which requires gown and glove in isolation rooms, removal of such before leaving the room and wearing of gloves when coming in contact with any potentially contaminated articles.

Policy #H-IC 02-002, Contact Precautions - Effective date 07/99; Revised 11/09 requires that employees;
-Don gloves and gown prior to entering a contact precautions room
-Remove and dispose of gown and gloves before leaving the patient's room and perform the appropriate form of hand hygiene immediately.
-If use of common equipment is unavoidable, then adequate cleaning and disinfecting is necessary upon removal from the room and before use with other patients.


















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