HospitalInspections.org

Based on review of medical records (MR), policies and procedures and staff interviews, it was determined the facility failed to ensure staff:

a) Obtained orders for care of a Central Venous Catheter (implanted port), provided and documented care as ordered or per facility procedure.

b) Performed wound care was as ordered.

c) Assessed wound sites to reflect appearance and progress or deterioration of the wound.

d) Administered tube feedings as ordered.

e) Flushed gastrostomy tube as ordered to ensure tube patency.

f) Provided follow-up for at risk patients and nutritional interventions.

g) Followed physician orders for hyperglycemia (elevated blood glucose).


This affected 4 of 5 records reviewed and included MR's # 1, # 3, # 5 and # 2. This had the potential to affect all patients treated at the facility.


Policy and Procedure
Subject: Central Venous Catheters
Date of Review: 04/16

"Policy: The following flushed/amounts are standardized: Venous access flushing and dressing change protocols:

Implanted Ports (Port-A-Cath)
Routine Flush-20 cc (cubic centimeter) NS (normal saline)
Post Blood/Chemical-20 cc NS
Heparin- 5cc 100 u(units)/ml
Dressing Change-7 days and PRN (as needed) when soiled..."



Policy and Procedure:

Subject: Skin Assessment and Wound Management

"...Procedure...
Assessment
4. If wound present, assess after cleansing:
Location
Size (length x [by] width and depth in centimeters
Color of of the wound bed (red, yellow, black, pink)
Undermining/sinus tracts
Amount/type color of drainage/exudate...
Odor
Tissue bleeding
Wound edges...
Condition of surrounding skin...

5. Notify the physician if the patient is exhibiting signs...infection..."

****

Policy

Dietician Activities
Title: Nutritional Assessment/Dietary Consult
Revised: 11/2014

Policy

"1. Nursing personnel shall complete an initial patient interview...Findings will trigger a nutritional consult if indicated.

Purpose:
1. To identify those patients at nutritional risk.
2. To develop a basis for nutritional intervention and follow-up.

Procedure:
1. Dietary consults are indicated by a physician's order, personal observation or triggered by initial interview admission form.
2. Registered Dietician will be notified by nursing staff and/or CPSI computer system regarding patient consults.
3. Special dietary needs will be discussed with the Registered Dietician for appropriate nutritional needs to be met.
4. In the event that the Registered Dietician is not in her office, appropriate phone numbers will be available so she may be reached by nursing staff at any time.


1. MR # 1 was admitted to the facility 5/9/16 with diagnoses including Dehydration, Colorectal Cancer and Anemia.

Record review included Emergency Room nursing documentation on 5/9/16 at 1:42 PM that revealed MR # 1 had a right anterior chest wall Port- A-Cath (catheter-CVC) with NS 0.9 % infusing at 150 ml (milliliter)/hr (hour). MR # 1 was admitted to the Medical unit at 1:59 PM.

Record review included ChartLink Physician Entered Orders that continued NS 0.9 % IV at 100 ml/hr. There were no orders for Port-A-Cath care including saline/ heparin flushes and dressing change.

There was no documentation nursing staff attempted to notify the physician for CVC care orders.

Review of the Initial Physical Assessment Nursing documentation dated 5/9/16 at 3:50 PM revealed an Implanted port with a 20 g (gauge) Huber needle. At 11:30 PM fluids were maintained at 100 cc/hr (cubic centimeters per hour) via (IV-intravenous) pump.

Further review revealed MR # 1 received 2 units of packed red blood cells on 5/10/16 from 4:00 PM to 11:35 PM via the CVC.

Review of the 5/11/16 Discharge Summary revealed the following documentation at 9:09 AM: "...Flushed with Heparin Flush 5 ML, D'cd (discontinued) with catheter tip intact, pressure and 2x2(gauze) applied...tolerated without difficulty..."

There was no documentation the Port-A-Cath was flushed with 20 cc NS and no documentation of the Heparin dosage/strength (10 units verses 100 units) CVC was flushed with.

In an interview on 5/17/16 at 3:50 PM, Employee Identifier (EI) # 1, Director of Nursing verified staff failed to confirm orders with the physician for care of the Implanted Port, provide and document CVC care performed.

2. MR # 3 was admitted to the facility 5/14/16 with diagnoses including Left Leg Burn and Diabetes Mellitus Type II.

Record review included ChartLink Physician Entered Orders dated 5/14/16 at 3:52 PM to wash (left leg) with Hibiclens and apply Silvadene BID (twice daily), cover (with) gauze, elevate leg.

Review of the 5/14/16, 5/15/16 and 5/16/16 nursing documentation failed to reveal wound care was provided as ordered.

There were no wound measurements or wound assessment documentation on 5/15/16 and 5/16/16.

MR # 3's medication included Humulin R Dose (regular insulin) sliding scale for blood glucose greater than 150 d/l (deciliter/liter).

Record review included a Diabetic Flowsheet which revealed a blood glucose of 210 on 5/14/16 at 4:34 PM. Sliding scale insulin orders were to administer Humalog 4 units for blood glucose 201-250.

There was no documentation Humalog 4 units was administered as ordered.

In an interview on 5/17/16 at 3:47 PM, EI # 1 confirmed the above findings.

3. MR # 5 was admitted to the facility 5/9/16 with diagnoses including Elevated INR (International Ratio) and Diverticulosis. The 5/9/16 History and Physical revealed MR # 3 currently has a gastrostomy tube.

Review of MR # 3's lab results revealed an Albumin 2.8, low (range 3.5-.5.5 g/dL (grams/deciliter). Albumin levels reveals amounts of protein stores.

Record review included ChartLink Physician Entered Orders dated 5/10/16 at 10:06 AM for Glucerna tube feedings at 6:00 AM, 2:00 PM and 10:00 PM. There were no orders for tube flushes before or after tube feedings to maintain gastrostomy tube patency.

Further review revealed ChartLink Physician Entered Orders dated 5/10/16 at 10:29 AM for 1 can Glucerna tube feeding at 10:00 AM.

Record review of the 5/10/16 at 10:10 AM nursing physical assessment documentation revealed the gastrostomy tube was flushed with 20 ml water, medications administered a 1 can of Glucerna. There was no documentation staff flushed the gastrostomy with 50 cc fluid before and after tube feedings.

Review of the Medication Administration Record and Nursing documentation on 5/10/16 failed to reveal staff administered Glucerna tube feeding as ordered at 2:00 PM on 5/10/16.

Record review included a Nutritional Assessment dated 5/11/16 completed by the Registered Dietician (RD) that contained the following recommendations: Pt (patient) receiving Glucerna 1 can three times daily with 50 cc fluid before and after. Consider increasing feeding to four times daily with 75 cc fluid before and 150 with meds to see if patient tolerates.

Further review of the RD assessment revealed MR # 3's estimated 24 hour calorie needs were 1513 with 66 gram of protein needs. MR # 3's current tube feeding order provided 711 calories (47 % of patient needs) and 29.7 grams of protein (45% of protein needs).

Record review failed to include documentation the physician and nursing staff acknowledged/declined or implemented RD recommendations.

In an interview on 5/17/16 at 3:16 PM, EI # 1 verified staff failed to administer tube feeding as ordered, notify the physician and confirm gastrostomy flush frequency and amounts. There was no documentation staff ensured the gastrostomy tube remained patent or performed nutritional intervention follow-up for the high risk patient.

4. MR # 2 was admitted to the facility 5/10/16 with diagnoses including Anemia, Chronic, Failure to Thrive, Dehydration and Unstageable Decubitus of the Other Site. MR # 2 had a gastrostomy tube.

Record review revealed ChartLink Physician Entered Orders dated 5/10/16 at 6:48 PM included "...Wound care per nsg (nursing) home...tube feeding as nsg home..."

Review of MR # 2's lab results included an Albumin 2.3, g/dL, (low).

Record review revealed nursing home wound orders as follows: Clean right hip and left hip with wound cleanser, pack with Dakins 0.25 % soaked gauze, then apply dry gauze, cover with ABD (abdominal) pads, secure with medipore tape, change daily; Clean open area to lower back and apply Duoderm change every 3-5 days and prn (as needed) loss of dressing.

Further review of the nursing home orders revealed Gastrostomy Status-Perative Formula 1 can three times a day and Ensure Plus one can daily by mouth.

Review of the 5/10/16 nursing documentation did not reveal Perative was administered until 5/11/16 at 2:47 PM. There was no Perative administered 5/10/16 at 10:00 PM or 5/11/16 at 6:00 PM, 2 missed doses.

Review of the 5/11/16 6:07 AM nurse documentation revealed the following: "...Dressing changed per orders...ABD pad, Damp to dry gauze packing, Xeroform..." There were no orders for Xeroform. There was no documentation staff cleansed the wound with wound cleanser, then packed with Dakins 0.25 % as ordered.

Review of the RD Nutritional Assessment dated 5/11/16 revealed MR # 3's estimated 24 hour calorie needs were 1527 and protein needs were 61 grams. MR # 3's current tube feeding order and Ensure provided 924 calories (61 % of patient needs) and 47.4 grams of protein (77% of protein needs).

Further review of the Nutritional Assessment revealed the following RD recommendations:"...Consider increasing tube feedings to 4 times per day to help with increased calories protein and fluids. Especially if po (by mouth) intake of Ensure is poor..."

Record review failed to include documentation the physician and nursing staff acknowledged/declined or implemented the above RD recommendations.

An interview conducted on 5/17/16 at 3:59 PM with EI # 1 revealed staff failed to obtain nursing home orders for wound care and tube feeding on 5/10/16. The Perative and Dakins were not available at the hospital and were picked up from the nursing home on 5/11/16. There was no documentation staff notified the physician the Perative Formula and Dakins Solution were not available for care as ordered.

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30952

Based on observations, review of the facility policies and procedures and interviews, it was determined the facility failed to ensure:

a) Staff performed handwashing and hand hygiene per facility policy.

b) Staff wore gloves during equipment cleaning.

c) Staff disinfected the glucometer after each patient use.

Findings include:

Policy and Procedure
Hand Hygiene for all Healthcare Workers
Date of Origin: 03/16

Purpose: To prevent the transmission of microorganisms from patient to patient and from inanimate surfaces to patients by the hands of all healthcare workers.

Policy:

Hand hygiene shall be practiced before and after each patient contact (even if gloves are worn)...

Gloves shall be worn when exposure to blood or any other body fluids, excretions or secretions is likely...

Routine Handwashing Procedure...

Dry well with paper towels and use the paper towels to turn off the faucet.

****

Recommendations for Hand Hygiene
Reference # 4009 Infection Prevention and Control

Indications for Handwashing and Hand Antisepsis...

Decontaminate hands after removing gloves.

Facility Policy
Topic: Cleaning the Microdot Meter
Date 3/11/2016

Policy:

This policy is to ensure that the Microdot blood glucose monitor is clean per manufacture guidelines.

Procedure:

"...2. use a lint free cloth dampened with alcohol to clean the outside or the...meter, or use a a 1:10 commercial bleach wipe...."


1. An observation was conducted on 5/16/16 at 11:10 AM with Employee Identifier (EI) # 4, Nursing Assistant to observe care provided including monitoring blood glucose testing using a glucometer.

EI # 4 completed blood glucose testing of an unsampled patient, removed and discarded gloves. EI # 4 failed to perform hand hygiene after glove removal and prior to inserting unclean hands into the clean glove box.

EI # 4 donned clean gloves without first performing hand hygiene, applied a telemetry monitor lead to the chest area of the unsampled patient, removed and discarded the gloves. EI # 4 failed to perform hand hygiene after glove removal.

EI # 4 retrieved a note pad and pen from his/her uniform pocket using unclean hands and documented the blood glucose reading. EI # 4 then used hand sanitizer and exited the room.

EI # 4 did not disinfect the glucometer after patient use.

EI # 4 entered the second patient room to perform blood glucose testing, donned gloves, then laid the glucometer on the patients bed, in direct contact with the blanket.

EI # 4 completed blood glucose testing and with gloved hands removed the paper and pen from his/her uniform pocket and documented the blood glucose value. EI # 4 retrieved the patient's urinal from the bedside, emptied the urinal into the toilet then removed/discarded gloves then used hand sanitizer.

EI # 4 placed the glucometer in the glucometer supply cart and exited the patient room into the hallway. EI # 4, with ungloved hands, disinfected the Microdot glucometer with a Clorox disposable wipe.

EI # 4 failed to disinfect the glucometer before placing the glucometer into the glucometer supply cart with clean supplies.

An interview with EI # 4 was conducted following the observations and were confirmed by EI # 4.

On 5/18/16 at 1:00 PM, EI # 2, Director of Pharmacy/Infection Control Preventionist confirmed staff failed to follow hand hygiene, disinfect the glucometer after patient use and wear gloves during equipment cleanings.

2. An observation was conducted on 5/16/16 at 11:55 AM with EI # 3, Registered Nurse (RN) to observe medication administration. EI # 3 performed handwashing at the sink in the medication room following administration of insulin. EI # 3 washed hands, then turned the faucet off with clean hands. EI # 3 failed to use paper towels to turn off the faucet.

An interview conducted on 5/16/16 at 11:59 AM with EI # 3 confirmed the above observation.

During an interview on 5/18/16 at 1:00 PM with Infection Control Coordinator, EI # 2 verified staff did not follow the hand hygiene policy.

3. During an observation of insulin preparation and administration, EI # 5, RN performed hand hygiene. EI # 5 retrieved insulin and supplies. EI # 5 performed hand hygiene, donned gloves and withdrew the insulin into the syringe.

EI # 5 removed and discarded the gloves. EI # 5 failed to perform hand hygiene immediately following glove removal.

EI # 5 then retrieved a medication label from the clean supply area and pen, then labeled the insulin syringe. EI # 5 exited the medication room, verified the insulin dosage with a staff nurse and entered the unsampled patients room.

EI # 5 reached into the clean glove box and retrieved gloves, then obtained hand sanitizer from the hand pump and sanitized after unclean hands were placed in the clean glove box.

An interview was conducted on 5/18/16 at 1:00 PM. EI # 2 verified staff failed to follow the hand hygiene policy.

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Kimberly Coan Hancock, RN, BSN