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Based on Medical Record (MR) and policy review and interviews, it was determined the hospital nursing staff failed to:

1. Obtain physician orders timely for wound care. This affected MR # 16.

2. Document measurements and assess wounds. This affected MR #'s 1, 16, and 19.

This had the potential to affect all patients with wounds.

Findings include:

Policy: Braden Scale for Predicting Pressure Sore Risk
Revised: July, 2012

Procedure: A.. Admission 1. Complete a Braden Scale for Predicting Pressure Sore Risk utilizing computerized system within 8 hours of admission on all patients. 2. For a score of 18 or less, the patient is considered at risk. Implement Pressure Prevention Protocol. 3. If any skin breakdown noted on assessment, consult WOCN (Wound Ostomy and Continence Nurse).

Medical Record Reviews:

1. Medical Record (MR) #16 was admitted on 11/24/12 with diagnoses including Infected Ulcers and Metabolic Encephalopathy.

A review of the history and physical, dated 11/24/12, revealed the patient was admitted with a left heel decubitus ulcer and a pressure sore on the left upper back.

A review of the initial physician's orders, dated 11/24/12, included a wound care consult only. There were no orders for treatment to the left heel and the left upper back areas.

A review of the initial nursing assessment documentation revealed a photograph of the left heel and left upper back areas with no identifiable measurements or staging of the wounds included.

A review of the nurses progress notes, dated 11/24/12 and 11/25/12, revealed documentation of Xeroform gauze, 4 x 4 and Kerlix intact to the areas on the left heel and left upper back. There were no orders for this treatment.

A wound consult was not conducted until 11/26/12 (two days after admission). The size of the pressure areas on the mid spine was 0.5 centimeters (cm) x 0.5 cm and the left heel was 4 cm x 5 cm, Stage 3. No wound depth was documented for the left heel.

The treatment orders, dated 11/26/12, included, "1. Waffle mattress. 2. Clean spine with Caraklenz, apply Santyl, cover with Xeroform and change daily. 3. Clean L (left) heel with Caraklenz, apply Santyl, cover with Xeroform and Kerlix change daily."

An interview conducted on 12/12/12 at 11:30 AM, with Employee Identifier (EI) # 1, Registered Nurse confirmed there were no wound care orders for MR # 16 until 11/26/12.


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2. MR #1 was admitted on 12/05/12 with diagnosis of Gastrointestinal Bleed.

A review of the history and physical, dated 12/05/12, revealed the patient was admitted with a decubitus ulcer on the sacrum, left heel and right heel.

A review of the initial nursing assessment dated 12/05/12 contained photographs of the sacrum and right and left heel ulcers. There was no documentation of measurements or stages of the wounds.

Review of the initial physician orders, dated 12/05/12, included a wound care consult and Santyl ointment to the sacral wound two times a day.

An interview conducted on 12/12/12 at 11:30 AM with EI # 1, Registered Nurse, confirmed the wounds were not measured and staged on admission.



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3. MR # 19 was admitted on 12/03/12 with diagnoses to include: Sepsis secondary to Pyelonephritis, Sacral Decubitus, Chronic Obstructive Pulmonary Disease (COPD) and Dementia.

The Nursing Shift Assessment dated 12/04/12 at
12:19 AM revealed MR # 19 had two wounds:
#1: Presssure ulcer to the sacrum.
Dressing type is documented as "wound vac." (Vacuum Assisted Closure)
Dressing Condition: Intact.
No picture of the sacral wound was found in the medical record.

#2: Ulcer to Right Ankle.
Dressing Type: Gauze/Kerlix
Dressing Condition: Intact

There was no documentation to indicate MR # 19's ankle wound was assessed. No measurement or photograph of the ankle wound was documented and/or found in the medical record.

A physician's order dated 12/03/12 at 8:00 PM, revealed, "Consult wound care for sacral decubitus."

A physician's order dated 12/05/12 revealed, "Wound Care Consult re (regarding) Sacral Decub (Decubitus) with WV" (Wound V.A.C. Vacuum Assisted Closure).

On 12/05/12 at 12:20 PM orders written "per protocol (MD's name/Wound Care RN/ EI # 1 revealed , "1. Wound vac to sacral ulcer. 2. Clean R (right) outer ankle with Carraklenz. Cover with Xeroform and wrap with Kerlix. Change daily."

Although the patient was admitted on 12/03/12, physician's orders for wound care were not obtained until 12/05/12. The order for wound V.A.C. (Vacuum Assisted Closure) to the sacral wound, written by EI # 1 on 12/05/12, failed to specify the type of setting for the wound V.A.C. : continuous or intermittent. The order also failed to specify the frequency of the dressing changes to the sacral wound.

No physician's order regarding wound care to MR # 19's ankle wound was obtained until 12/05/12.

During an interview on 12/12/12 at 11:30 AM, EI # 2, RN / Charge Nurse, stated patient wounds should be photographed and measured on admission. EI # 2 verified no measurements or photographs were obtained on admission for MR # 19's wounds.

On 12/12/12 at 2:00 PM, the survey team requested the hospital's policy for wound V.A.C. therapy from the Executive Director of Nursing / EI # 4. However, no policy was provided.

Based on observations during the facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.


Findings were:

Refer to the Life Safety Code survey report for findings.

Based on facility policy, observations and interviews with facility staff, and review of the U. S. Health Public Food Code, it was determined the facility failed to ensure:

1. All equipment was cleaned and maintained in a safe and conducive way to prevent falls.

2. Storage of pots and pans were stored according to facility policy.


U. S. Department of Health and Human Services 2009 Food Code

4-9 Protection of Clean Items

Drying

4-901.11 Equipment and Utensils, Air-Drying Required.

After cleaning and Sanitizing, Equipment and Utensils:

(A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR (Code of Federal Regulations) 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface Sanitizing solutions), before contact with Food; and

(B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry.

Storing

4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles.

(A)Except as specified in (D) of this section, cleaned Equipment and utensils ....shall be stored:

(1)In a clean, dry location

(2)Where they are not exposed to splash, dust, or other contamination ....

(B) Clean Equipment and Utensils shall be stored as specified under (A) of this section and shall be stored:

(1) In a self-draining position that allows air drying; and

(2) Covered or inverted.


Policy # F017
Date Revised: 11/09

Subject: Storage of Pots, Dishes, Flatware, and Utensils

Procedures:
Air dry all food contact surfaces, including pots, dishes, flatware, and utensils before storage, or store in a self draining position. Do not stack or store when wet.

Findings:

A tour was conducted 12/10/12 at 10:20 AM to 11:45 AM of the Dietary Department, by the surveyor and Employee Identifier (EI) # 3, Dietary Manager. During the tour the walk in freezer floor was observed with thick ice accumulation and debris, making it unsafe and a potential hazard for falls.

The surveyor also observed, in the pot and pan area, several long pans stacked on the designated "clean" rack which were wet nested. Wet nesting is a potential for bacterial growth. The staff failed to follow the facility policy for storage of pots.

An interview was conducted with EI # 3, after the tour, at 11:45 AM,who confirmed the above findings and verified the staff failed to follow the facility policy.