HospitalInspections.org

Based on observation, document review and interview, the facility did not ensure patient care was provided in a safe setting. This was evident in: (A) Inconsistent implementation of the falls precautions policy; (B) Unsecured storage of insulin syringes, blood draw needles and lancets; and (C) Lack of specimen labeling at the patient's bedside.

These lapses in patient and environmental safety place patients at increased risk for injury.

Findings pertinent to (A) include:

Observations in the facility's nursing units on 5/21/18 and 5/22/18 identified the following:

On 5/21/18 at 10:35AM, Patient #20, assessed and identified as a fall risk, did not have fall risk signage outside their room or on the communication whiteboard in their room.

On 5/21/18 at 10:35 AM, Patient #33, assessed and identified as a fall risk, did not have green non-slip foot wear nor fall risk signage on the communication whiteboard in their room.

On 5/22/18, at 9:10AM, Patient #29, assessed and identified as a fall risk, did not have a green fall risk bracelet.

Similar findings for the inconsistent implementation of the Falls Prevention policy were observed for Patient #'s 21, 22, 31, and 32.

These observations were confirmed with Staff Q (Nurse Manager).

The facility Policy and Procedure (P&P) titled "Falls Prevention," last revised 7/14/2016, stated, "Activate fall prevention for high risk: Apply a green fall risk bracelet to the patient's wrist, obtain green non-slip footwear for the patient, apply fall risk signage on the whiteboard, and apply fall risk signage to the outside of the patient's room."


Findings pertinent to (B) include:

Observations in the facility's nursing units on 5/21/18, 5/22/18 and 5/23/18, identified the following:

On 5/21/18 at 2:05PM, a medication cart containing insulin syringes was found opened and unattended outside patient room #420.

On 5/22/18 at 9:25AM, a phlebotomy supply cart containing phlebotomy needles, with a functioning locking mechanism, was found unlocked, unsecured and unattended in the hallway directly outside of a patient's room.

On 5/23/18 at 11:45AM, a supply box containing lancets was found unsecured and unattended on a supply cart.

These observations were made in the presence of Staff Q, who acknowledged the carts and supply box should have been secured.

The facility's "Nursing Orientation," dated 2018, contained the following statement: "Sharps should always be stored in a locked secure location."

The facility's P&P titled "Lab Phleb Safety and Supplies," last revised 7/31/2017, lacked guidance directing the phlebotomy staff to lock supply carts when unattended.


Findings pertinent to (C):

On 5/21/18 at 2:00PM, Staff M (Phlebotomist) was observed labeling the blood specimen tubes of a patient on contact and droplet precautions, outside of the patient's room, at his supply cart, and not at the patient's bedside as specified in the facility policy.

On 5/22/18 at 9:20AM, Staff N (Phlebotomist) was observed walking to the nursing station with a pink blood specimen tube in his hands. The staff member retrieved a patient's chart, removed a patient label, and affixed it to the tube of blood while at the nursing station.

These observations were confirmed by Staff Q.

The facility P&P titled "Lab Phleb Specimen Collection and Handling," last revised 01/24/2018, contained the following statements: "Label tubes in presence of patient and complete documentation as necessary .... all tubes must be labeled in the presence of the patient after the tubes are filled at either the bed or the drawing chair."

Based on medical record (MR) review, document review and interview, in three (3) of six (6) medical records, the nursing staff did not formulate a nursing care plan to meet the changing skin care needs of patients. This lack of revision to the nursing care plan placed patients at risk for developing further skin breakdown.

Findings include:

Patient #50's MR identified the patient was admitted on 04/01/2018 with a diagnosis of Respiratory Failure, Hypoxia, Aspiration Pneumonia and Sepsis. The patient was documented to have sacral, buttock, left and right heel pressure injuries on 04/04/2018. However, there was no documented evidence that the nursing staff revised the patient's nursing "Plan of Care" to include "Skin Integrity Impairment Risk" until 5/21/18, 48 (forty-eight) days after admission.

The same problem in documenting the initiation of a care plan was identified for Patient #51.

These findings were confirmed by Staff L (Clinical Informatic Specialist) on 5/24/2018.

Patient #8's MR identified this patient was admitted on 5/16/18 and had a Stage II Sacral Pressure Ulcer present on admission. Nursing care plan initiated on admission did not reflect Skin Integrity as an active problem. Patient #8 did not have an active Skin Integrity Plan of Care for 6 (six) days after admission.

During interview of Staff L on 5/22/18 at 3:00PM, she confirmed this finding. Staff L stated that the skin integrity problem should have been identified and activated on admission.

The policy titled "Admission Assessment", last reviewed 06/29/2016 stated: "Reassessment of the patient's condition and needs occurs at least twice in 24 hours...and also upon a change in the patient's condition ...[and]...the entire plan must be ...updated once every 24 hours."

Based on Medical Record (MR) review, document review and interview, in two (2) of six (6) MRs, the Nursing Staff did not accurately document skin reassessments for patients with evidence of skin alterations. This inconsistent assessment documentation may affect other providers' ability to monitor patients' condition or provide appropriate care.

Findings include:

The Policy & Procedure (P&P) titled, "Wound Assessment, Prevention, Management and Documentation," last reviewed 06/09/2016 stated; "all prevention, assessment and management strategies are to be documented in the patient's medical record .... these assessments are to be documented every shift, on transfer to another unit and with a significant change in the patient's condition."

Patient #50's MR identified the patient was admitted on 04/01/2018 with a diagnosis of Respiratory Failure, Hypoxia, Aspiration Pneumonia and Sepsis. On 4/11/18 at 8:57 AM, the wound care nurse documented the patient had developed a Stage II intact blister pressure injury of the left heel, 4 inches wide with surrounding erythema.

The pressure injury daily documentation by the nursing staff then remained unchanged until 4/24/18, when the wound care nurse reassessed the patient and documented the pressure injury was now a Deep Tissue Injury (DTI) 3 inches wide with purple coloration. The nursing documentation of the pressure injury then again remained unchanged until 5/2/18, when the wound care nurse documented the heel DTI was 2 inches wide.

The pressure injury nursing documentation continued unchanged until 5/16/18, when the wound care nurse assessed the patient and updated the wound characteristics from "closed" to "closed with eschar / necrotic."

The same, unchanged daily nursing assessment documentation was found between the wound care nurse's reassessments for the pressure injury on the patient's sacrum, making it difficult to determine when the patient's pressure injuries changed between the wound care nurse's assessments and documentation.

Patient #49's MR identified the patient was admitted with Aspiration Pneumonia and Sepsis on 2/19/18. On 2/28/18 the wound care nurse documented the patient had bilateral heel pressure injuries with blanchable redness. The daily pressure injury documentation by the nursing staff then remained unchanged until 3/7/18, when the wound care nurse reassessed the patient and documented the pressure injury was now bilateral heel Stage II intact fluid filled blister, 3 inches by 3 inches, nine hours after the nurse documented the pressure injury was unchanged. These findings were confirmed by Staff L (Clinical Informatic Specialist) during review of the MRs on 5/24/2018.

Based on observation, document review, MR (medical record) review and interview, in 1 (one) of 3 (three) observations, the staff failed to ensure a patient's own medications were returned to them upon discharge.

Observation in the facility's 3 North unit during a tour on 5/21/18 between 10:30AM and 12:20PM, identified 2 (two) medications belonging to Patient #43, found on a shelf in the medication room. The medications were labeled from both an outside pharmacy and the facility's pharmacy.

This was confirmed with Staff G (Nurse Manager) and Staff X (Clinical Educator) at the time of the observation. Staff G stated that Patient #43 had been discharged from the facility and those were the patient's own medications; the medications are kept on the unit since the pharmacy department doesn't keep them. Staff G also stated the unit staff will usually try to contact the patient(s) at home to return to pick up any belongings, but those attempts were not documented.

Review of Patient #43's MR revealed the patient was discharged on 12/22/17, 5 (five) months before the medications were found in the medication room. The patient's Discharge Medication List, dated 12/22/17, listed both medications were to be continued after discharge. The nurse's clinical notes dated 12/22/17 at 10:20AM stated, "Patient D/C [discharge] to Home ...All belong[ings] taken with Patient".

The facility Policy and Procedure (P&P) titled, "Patient's Own Medications," last revised 5/21/18 stated, "Pharmacy will have a daily printout of non-formulary (NF) meds, by floor. It will be generated for the unit pharmacists who will indicate medications that should be followed up on ... Non-controlled patient's own medications will normally be stored in the patient's medication bin...A log will be maintained in the pharmacy to track the patient's own medication in and out of the department". This policy lacked guidance regarding how to handle patient's own medications that are not returned to the patient upon discharge.

Per interview with Staff I (Director of Pharmacy) and Staff J (Pharmacist) on 5/22/18 between 3:00PM and 3:35PM, they stated the Pharmacy department inspects the medication rooms monthly.

A review of the pharmacy's Monthly Patient Care Unit Inspection sheets from 1/18 to 5/18, revealed the item "Medications from discharged patients have been returned to Pharmacy" had been checked "Yes." No other documentation was provided for Patient # 43's medications found in the medication room, 5 (five) months after patient's discharge.

Based on observation, document review and interview, the facility staff did not ensure care was consistently provided within acceptable standards of infection control practices. Breaches in infection control were evidenced by: (A) Lack of Hand Hygiene; (B) Cross contamination of equipment and supplies in 3 (three) of 3 (three) observations; and (C) Lack of date labeling of Intravenous (IV) tubing in 11 of 16 observations; IV locks in 9 of 16 observations; and Tube Feeds in 1 of 2 observations.

These lapses in Infection Control practices placed all patients at increased risk for infections.

Findings pertinent to (A):

Observations in the facility's nursing units on 5/21/18, between 10:30AM and 3:00PM, identified the following:

Staff P (Nursing Assistant) exited a patient's room with donned gloves. The staff member removed the contaminated gloves and, without performing hand hygiene, retrieved and donned new gloves.

Staff M (Phlebotomist) exited the isolation room of a patient on contact and droplet precautions. Staff M removed all his Personal Protective Equipment (PPE) and without performing hand hygiene, walked to his supply cart, labeled the blood specimen tube, and retrieved clean supplies from the cart.

These observations were confirmed with Staff Q (Nurse Manager), who intercepted the staff members and instructed them to perform hand hygiene.

During observations on the 4 North nursing unit between 9:30AM and 12:00PM on 5/23/18, Staff AA (Registered Nurse) was in an isolation room, administering medication to a patient on contact and droplet precautions. Staff AA removed her contaminated gloves in the patient's room, and without performing hand hygiene, retrieved new gloves and donned them.

During interview of Staff AA at the time of the observation, she acknowledged the findings.

Similar findings of failure to perform hand hygiene after patient contact were observed for Staff H and Staff Y.

The facility policy and procedure titled "Hand hygiene," last revised 5/18/2017, instructed staff to "perform hand hygiene before and after patient contact, after touching any objects likely to be contaminated in a patient care environment ... prior to donning gloves and after removing gloves."

Findings pertinent to (B):

On 5/22/18 at 11:30AM, Staff W (Registered Nurse) was observed performing blood glucose testing on Patient #35. The staff member touched the patient during the identification process with gloved hands, opened the bottle of glucose test strips and retrieved a strip, contaminating the bottle and strips.

During observations of the 4 North nursing unit between 9:30AM and 12:00PM on 5/23/18, Staff AA, (Registered Nurse) was observed administering medication to a patient on contact and droplet precautions. Staff AA then picked up a medication cup from the floor and discarded the cup. Staff AA failed to remove her contaminated gloves, perform hand hygiene and don new gloves before retrieving the Sani wipes from the dispenser and cross-contaminating her medication cart.

During interview of Staff AA, at the time of the observation, the staff member acknowledged the findings.

Similar findings of cross contamination of equipment and supplies were observed for Staff members M, N and O.

These observations were made in the presence of Staff Q, who acknowledged the findings.

The facility policy and procedure titled "Hand hygiene," last revised 5/18/2017, instructs staff to perform hand hygiene before and after patient contact, after touching any objects likely to be contaminated in a patient care environment ... prior to donning gloves and after removing gloves... wear gloves to reduce the risk of personnel acquiring infections from patients, and to prevent health-care worker flora from being transmitted to patients ... wear gloves when contact with blood, body fluids, potential infectious products ... "


Findings pertinent to (C):

Observations of the facility's nursing units during a tour between 10:30AM and 3:00PM on 5/21/18, identified the following:

Patient #34 was observed with Jevity tube feeds in progress, IV Vancomycin medication and Normal Saline IV fluid (IVF) in progress, and an IV catheter site that did not have labels indicating the initiation or insertion dates in place.

Per interview of Staff S (Registered Nurse) at the time of the observation, the staff member acknowledged the tube feed tubing, IV medication, IVF tubing and IV catheter site should have all been labeled with initiation or placement dates.

Patient #22 was observed with IV Piperacillin Tazobactam and Saline in progress without labels indicating the dates they were initiated, and an IV catheter site without a label indicating the placement date.

Similar findings of IV tubing and IV catheter sites not dated were observed for patients #18, 19, 23, 24, 25, 26 and 27.

These observations were made in the presence of Staff Q, who acknowledged the tubing for the IV medications, the tube feed, and IV catheter sites should have been dated.

The facility policy and procedure (P&P) titled "Intravenous Catheter, Intermittent Intravenous (Piggyback) Insertion and Management," last revised 09/16/2016, contained the following statements: "when there are two or more IV lines, the tubing shall be labeled at the pump insertion site ...the IV site and IV tubing (primary and secondary) is to be changed every three (3) days (72 hrs.); to decrease the possibility of contamination of site ...attach the secondary set via Leur lock connection and date the tubing."