HospitalInspections.org

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Based on document review, Medical Record review and interview in two (2) of ten (10) Medical Records, the Nursing Staff did not ensure that Nursing Care Plans were initiated and revised as per facility policy.

This failure to consistently review Nursing Care Plans may lead to delays and/or lack of treatment and care.

Findings:

The facility Policy and Procedure titled "Interdisciplinary Plan of Care Provision of Care, Treatment and Services" last revised 03/07/2018, stated the following: "The health care team prioritizes each patient care and services to ensure that the patients' most pressing needs are met. The plan of care is initiated within eight (8) hours of admission ... reviewed by members of the team and updated as appropriate to reflect the patient condition and ongoing health care needs .... The plan of care is modified based on ongoing evaluations ... to ensure that the patients' needs are ... addressed."

Patient #29's Medical Record identified this 75-year-old female, with a past medical history of PVD (Peripheral Vascular Disease), HTN (Hypertension), HLD (Hyperlipidemia), AFib. (Atrial Fibrillation) and CVA (Cerebro-Vascular Accident) with left-sided weakness and was admitted on 09/05/18 with a UTI (Urinary Tract Infection). This patient was noted to be an Insulin-Dependent Diabetic and was documented to have multiple pressure injuries. The Nursing staff initiated a plan of care on admission, which they re-evaluated on 09/07/18. However, there is no documented evidence that the Nursing staff revised the plan of care to include "pressure injury prevention / treatment" and "the risk of abnormal glucose levels".

Per interviews in the afternoon of 09/07/18, Staff D (Assistant Director of Nursing {ADN}) and Staff E (Nurse Manager), confirmed these findings.

Review of Patient #2's Medical Record revealed that this patient was admitted on 03/31/18 at 10:32AM. The plan of care was not initiated until 04/02/18 at 11:15AM, forty-eight (48) hours and forty-three (43) minutes after admission.

During an interview with Staff K (Informatic Nurse) on 09/06/18 at 1:30PM Staff K confirmed the care plan had not been initiated in a timely manner and had not been initiated within eight (8) hours of admission as per facility policy.
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Based on observation, document review and interview, the facility staff did not ensure that care was consistently provided within acceptable standards of Infection Control Practices. Breaches in Infection Control were evidenced by: (A) Lack of hand hygiene in eight (8) of sixteen (16) observations; (B) Cross-contamination when moving from contaminated to clean tasks in three (3) of four (4) observations; and (C) Improper use of Personal Protective Equipment (PPE) in two (2) of four (4) observations.

These lapses in Infection Control Practices placed all patients at increased risk for infection.

Findings pertinent to (A):

Observations in the facility's 18 North Unit during a tour between 2:00PM and 3:15PM on 09/05/18 identified the following:

Staff F (Registered Nurse {RN}) was administering blood products to Patient #15, a patient on Contact Isolation for Methicillin-Resistant Staphylococcus Aureus (MRSA) in the nares. Staff F removed her contaminated gloves, then without performing hand hygiene, donned new gloves.

Staff G (RN) was assisting Staff F during the administration of blood products to Patient #15. Staff G removed her dirty gloves, then without performing hand hygiene, retrieved a new pair of gloves and donned them. This same staff member was again observed retrieving new gloves from a box with dirty gloves donned.

These observations were made in the presence of Staff H (Assistant Director of Nursing) and Staff I (Nurse Manager) who acknowledged these findings.

Similar findings of the failure to perform hand hygiene between glove changes were observed for Staff J (Nurse Specialist), Staff O (RN), Staff P (Certified Nursing Assistant {CNA}), Staff S (CNA), Staff V (RN) and Staff W (RN).

The facility Policy and Procedure titled "Hand Hygiene" last revised 12/06/17, directed staff to perform hand hygiene before donning gloves and after removing gloves.

Findings pertinent to (B):

Observations in the facility's Cardio-Thoracic Intensive Care Unit on 09/10/18 between 9:45AM and 10:30AM identified the following:

Staff V (RN) was observed administering medication via a central line. After administering the medication, Staff V entered the clean supply cart without removing their gloves.

Staff V lifted the garbage can lid with the same gloves, and without changing the gloves and sanitizing their hands, reached into the clean supply cart a second time, retrieved an intravenous (IV) cap, and using the same gloves, recapped the patient's central line.

This observation was made in the presence of Staff B (Assistant Director of Nursing) and Staff Y (Nurse Manager) who confirmed these findings.

Observations in the facility's Critical Intensive Care Unit on 09/10/18 between 10:30AM and 11:00AM identified the following:

Staff W (RN) was observed picking up Chux and diapers off the top of the dirty linen can and placing them on the shelf at the bottom of the clean linen cart.

Without performing hand hygiene, Staff W then changed one (1) glove, and accessed the clean supply cart with one (1) clean gloved hand and one (1) contaminated gloved hand. Staff W then took one of the contaminated Chux, that had previously been lying on the dirty linen can, and placed it across the patient's chest, under the oral feeding tube without changing gloves or performing hand hygiene. Staff W proceeded to administer medications via the feeding tube.

This observation was made in the presence of Staff B and Staff Z (Nurse Manager) who confirmed these findings.

Similar findings of the failure to perform hand hygiene and change gloves when moving from a contaminated to a clean task were observed for Staff O (RN).

The facility provided Infection Control Education titled "General Recertification 2018" which instructed staff to "remove gloves and perform hand hygiene when going from a contaminated to a clean body site" and "Perform hand hygiene before, after and between direct contact with patients ... i.e.: between contact, cleaning hands after a patient care activity, moving to a non-patient care activity, and cleaning hands again before returning to perform patient contact."

Findings pertinent to (C):

Observations in the facility's Critical Intensive Care Unit on 09/10/18 between 10:30AM and 11:00AM identified the following:

Staff W (RN) was observed in a Droplet Precautions Isolation Room with "clean" masks in her pocket. Staff W was then observed carrying the pocketed masks into another patient's [Non-Isolation] Room from the Droplet Precautions Isolation Room.

Staff AA (Attending Medical Doctor {MD}) was observed in the same Isolation Room with a mask donned. Staff AA then exited the room with his mask still donned and walked across the hall to obtain equipment from the Clean Supply Room.

After performing a procedure in the Droplet Precaution Isolation Room with Staff AA, Staff BB (Fellow MD) exited the Isolation Room without doffing his mask and proceeded to have a conversation with the patient's family in the hallway while wearing his contaminated mask.

Per interview with Staff B (Assistant Director of Nursing) at the time of observation, all PPE should have been removed prior to exiting the Isolation Room.

The facility Policy and Procedure titled "Isolation Precautions" last dated 07/08/18, lacked instructions for staff to remove PPE when exiting Isolation Rooms.