HospitalInspections.org

Based on observations of care, review of medical records (MR), facility policy and procedure and staff interviews, it was determined the facility failed to perform ordered care and document care provided per facility policy. This affected 2 of 7 MR's reviewed and did affect MR's # 6 and 7. This had the potential to affect all patients served by the facility.

Findings include:

Patient Care Policy and Procedure
"Title: IV (intravenous) Therapy...Care of Central Venous Catheters..."
Review Dates: 5/14

I. Purpose
The purpose of this policy is to ensure safe and effective management of central venous catheter usage.
IV. Definitions of Terms
B. Chlorhexidine Gluconate (CHG) is an antimicrobial agent.
D...Examples of tunneled catheters are...Implantable port-a-cath (catheter)...

B. Care of Central Venous Catheters
Routine ...sterile dressing change every Wednesday with the use of biocclusive dressing...
2. Procedure
a. Routine...catheter care and sterile dressing change every 7 days with the use of biocclusive dressing...
3. Remove dressing
4. Put on mask and sterile gloves
5. Clean site thoroughly with CHG using back and forth motion. Allow to dry.
6. Cover with biocclusive dressing...
i. Document the following:
1. Condition of site.
2. Care required..."


1. MR # 6 was admitted to the facility on 7/18/15 with diagnoses including vomiting.

On 7/22/15 at 10:15 AM, care of a Central Venous Catheter (CVC), an Infusaport was observed with Employee Indentifer (EI) # 4, Registered Nurse (RN). EI # 1, Chief Nursing Officer was present during the observation.

EI # 4 flushed the Infusaport with 10 cubic centimeters of normal saline, removed the old Infusaport site dressing, using sterile technique cleaned the site surrounding the Huber needle with a Chlorhexadine sponge. EI # 4 then cleaned the Huber needle site and lumens with 3 alcohol swabs from the catheter kit, applied the biopatch and biocclusive dressing.

Review of the record revealed a 7/22/15 physicians order to change the Implanted Port (Infusaport) Dressing on Wednesday. The physician's order for care of the Infusaport was not specific for the Infusaport care and dressing change.

In an interview on 7/22/15 at 10:35 AM with EI # 12, RN, Unit Manager was asked by the surveyor how the RN's knew what Infusaport site care and dressing change to perform? EI # 12 responded "they follow our protocol".

Review of MR # 6 revealed the Infusaport site care had previously been completed 7/22/15 at 6:02 AM. The following documentation was completed on the CVC dressing change performed 7/22/15 at 6:02 AM: "...Date needle changed Infusaport-7/22/15...Site interventions Infusaport- flushed with saline, Type dressing applied- Infusaport (site) Occlusive dressing.

There was no documentation the Infusaport site was cleaned with the appropriate antimicrobial, Chlorhexidine. There was no documentation of the size Huber needle inserted with the needle change.

The medical record failed to contain complete information and documentation for interventions performed and care ordered and provided to the Infusaport site.

In an interview on 7/24/15 at 11:30 AM, EI # 2, RN, Director of Quality Management verified the above finding.

2. MR # 7 was admitted to the facility on 7/9/15 with diagnoses including Other sequelae of Chronic Liver Disease.

Review of MR # 7 revealed a physician's orders dated 7/9/15 for urinary catheter care twice daily.

Record review revealed urinary catheter care was not documented as completed the following dates:

7/11/15-no afternoon/evening urinary catheter care documented
7/13/15-no morning urinary catheter care documented
7/14/15-no afternoon/evening urinary catheter care documented
7/16/15-no morning urinary catheter care documented
7/17/15-no morning or afternoon/evening urinary catheter care documented
7/18/15-no afternoon/evening urinary catheter care documented
7/19/15-no morning urinary catheter care documented

In an interview with EI # 12 on 7/23/15 at 12:10 PM, the aforementationed findings were confirmed.

Based on review of facility policies and procedures, Potter-Perry Fundamentals of Nursing practice standards, observations and interviews, it was determined the facility failed to ensure staff:

1) Performed hand hygiene according to facility policy.

2) Performed cleaning of the Precision Xceed Pro glucose test monitor between patient use as per facility policy.

3) Prepared IV (Intravenous) medication according to nurse practice standards.

This had the potential to negatively affect all patients and staff within the facility.

Findings include:


Infection Prevention - Hand Hygiene

"V. Policy:
To disrupt the transmission of microorganisms, health care workers are to practice hand hygiene at key points in time such as the following
a. Before patient contact
b. After contact with blood or body fluids
c. After contact with dirty surfaces (even if gloves are worn)
d Before invasive procedures
e. After removing gloves (wearing gloves is not enough to prevent transmission of pathogens in health care settings)

VI. Procedure
Hand Washing
...e. Turn off faucet with paper towels and discard.
f. Dry hands with a clean paper towel and discard..."

Policy:

Title: Glucose Testing System/Medisense Precision Xceed Pro
(No number or date)

" Maintenance

The Precision Xceed Pro Monitor requires..routine maintenance...

Cleaning

Cleaning the exterior surface of the Precision Xceed Pro Monitor should be cleaned between patients. Acceptable cleaning solutions include alcohol and ammonia based cleaners..."


Potter-Perry Fundamentals of Nursing
6th Edition
Preparing Injections
Chapter 34; pg 877

" Preparing Injections

B. Vial containing a solution
(1) Remove cap covering top of unused vial to expose sterile seal, keeping rubber sterile...Firmly and briskly wipe surface of rubber seal with alcohol swab and allow to dry.

Rationale
...Not all drug manufactures guarantee that caps of unused vials are sterile. Therefore seals must be swabbed with alcohol before preparing medication..."

1. An observation conducted on 7/23/15 at 2:00 PM of Employee Identifier (EI) # 8, Phlebotomist, draw blood for blood cultures from 2 different sites revealed the following. EI # 8 removed gloves after drawing the first set of blood cultures and donned clean gloves without using hand sanitizer or washing hands. After completing the second set of blood cultures, EI # 8 removed gloves and discarded them and failed to wash hands or use hand sanitizer.

An interview was conducted 7/23/15 at 2:45 PM with EI # 2, Registered Nurse (RN), Director of Quality Management who verified the policy was to use either hand sanitizer or wash hands with soap and water between glove change. EI # 8 failed to follow the policy for hand hygiene.

2. An observation on 7/24/15 at 9:15 of EI # 9, RN, Intensive Care Unit, wash hands during assisting with wound care revealed the following. EI # 9 washed hands between glove changes 3 different times with soap and water and failed to turn off the water faucet with paper towels.

An interview was conducted 7/24/15 at 10:45 AM with EI # 2 who verified the policy for hand hygiene was not followed.




30952

During an observation of care performed on 7/22/15 at 10:20 AM, Employee Identifier (EI) # 4, Registered Nurse (RN) performed site care on a central venous catheter (CVC), an Infusaport.

EI # 4 wearing clean nonsterile gloves, opened the CVC care kit, donned the mask, and removed the Infusaport dressing. EI # 4 removed and discarded the nonsterile gloves. EI # 4 then donned the pair of sterile gloves. EI # 4 failed to perform hand hygiene after glove removal.

EI # 4 cleansed the site with Chlorprep and alcohol, applied the biopatch then removed and discarded the sterile gloves. EI # 4 requested an additional pair of sterile gloves which were retrieved by EI # 1, Chief Nursing Officer, present during the observation. EI # 4 failed to perform hand hygiene after removal of the sterile gloves and donning the new sterile glove pair.

EI # 4 applied a transparent occlusive dressing the Infusaport site, removed and discarded the gloves. EI # 4 then labeled the dressing. EI # 4 again failed to perform hand hygiene immediately following glove removal.


Observations of care that included testing of patient blood glucose levels was performed on 7/22/15 between 11:40 AM and 12:10 PM by EI # 5, Patient Care Technician. EI # 1 was present during the observations.

EI # 5 performed glucose testing on 3 patients using the Precision Xceed Pro Monitor. EI # 5 failed to clean the Precision Xceed Pro Monitor between patient use as required by facility policy and procedure.

During interviews on 7/23/15 at 10:20 AM, EI # 1 verified the above findings.


On 7/23/15 at 9:50 AM during an observation of care, EI # 6, RN, prepared and administered Bumex IV.

EI # 6 opened a single use vial of Bumex and withdrew the Bumex into a syringe. EI # 6 did not clean the septum of the Bumex vial with alcohol prior to needle insertion.

EI # 6 completed the medication administration, removed and discarded the right glove only and documented on the computer using the right hand. EI # 6 did not remove gloves and perform hand hygiene.

EI # 6 then performed hand hygiene at the sink. EI # 6 turned the faucet off using clean wet hands. EI # 6 failed to perform hand hygiene per facility policy and turn the faucet off using a paper towel.

In an interview on 7/23/15 at 10:20 AM, EI # 6 verified the above observations.

On 7/23/15 at 10:40 AM, EI # 7, Housekeeper performed an environmental cleaning of a vacated patient room.

EI # 7 entered the room and performed hand hygiene at the sink. EI # 7 turned the faucet off with clean wet hands.

EI # 7 failed to perform hand hygiene per facility policy and turn the faucet off with the paper towel.

Based on review of medical records, (MR) facility policy and staff interviews, it was determined the facility failed to obtain a signed provider choice form for 3 of 3 records reviewed with hospice and skilled nursing facility (SNF) transfers. This did affect MR's # 1, 4 and 5 and had the potential to affect all patients referred to home care, hospice and SNF's.

Findings include:

Policy:

Title: Case Management-Discharge Planning

Review/Revision Dates: 7/8/15

Procedure for Case Management Intervention:

"4. Patient referrals will be made once the appropriate level of aftercare is determined, agreed upon, and with a physician's order...Referrals will be made to outside agencies...the available providers and patient/family preference. A provider option list will be provided to the patient/family and a provider choice from will be signed by the patient/family acknowledging receipt/discussion of provider options. In the event the patient is unable to sign the provider options form and family contact is by phone, the case manager will..."per phone consent" on the provider option form..."

On 7/23/15 between 1:00 PM and 3:30 PM, record reviews for the purpose of discharge planning review were conducted with Employee Identifier's (EI) # 10 and #11, Case Managers.

Record reviews revealed MR's # 1 and 5 were transferred from the facility to SNF's at discharge. There was no provider choice form, signed by the patient/family in the medical record.

MR # 4 was discharged from the facility to hospice care. There was no provider choice form, signed by the patient in the medical record.

During interviews on 7/23/15 at 3:20 PM, EI # 10 and # 11 confirmed the facility had failed to obtain a signed provider choice form upon discharge.