HospitalInspections.org

Based on interview and record review the hospital failed to ensure RN's (Registered Nurses) assessed/evaluated and/or ensured repositioning was provided for 1 of 5 dependent patients (Patient #5). (Patient #5) developed excoriation to the coccyx and a stage I pressure ulcer to the left hip.

Findings included:

Patient #5's Integrated Psychiatric Assessment dated 02/19/13 timed at 13:15 PM reflected, "Patient has been agitated and confused...used wheelchair...total assist with dressing, toileting and mobility/transfer..."

The Initial Nursing Assessment and Admission Data dated 02/19/13 timed at 21:56 PM reflected, "Urinary incontinence...skin intact...multiple bruises on both arms..." No further skin problems were noted on admission.

The every 15 minute observation forms dated 03/12/13 through 03/13/13 reflected no documentation which indicated Patient #5 was repositioned every two hours.

On 03/13/13 at 06:00 AM Patient #5 was observed lying in bed positioned on the left side. At 07:05 AM Hospital Staff #10 and #13 provided incontinent care for Patient #5. The surveyor observed during care Patient #5 had a reddened area over Patient #5's left hip and Patient #5's coccyx was dark red in appearance. Hospital Staff #13 was asked when Patient #5 was last repositioned. Hospital Staff #13 did not answer. At 07:15 AM the surveyor went to the nursing station and asked Hospital Staff #22 how she ensured repositioning was done for dependent patients. Hospital Staff #22 reviewed the rounds record and stated the technician did not document every two hour repositioning was completed. At approximately 07:40 AM Patient #5 was placed in the wheelchair and brought out to the dayroom.

On 03/13/13 at approximately 09:00 AM Hospital Staff #8 was interviewed. Hospital Staff #8 was asked by the surveyor what information she had received in report regarding Patient #5. Hospital Staff #8 stated she was informed Patient #5 had a red coccyx. Hospital Staff #8 stated the night nurse said nothing about a red area to Patient #5's left hip.

The 03/13/13 11 PM-7 AM shift Daily Nursing Assessment/observation record timed at 08:15 AM reflected, "Patient in bed most of the night...patient brief changed...no signs/symptoms of acute distress...will continue to monitor..." No night shift documentation was found regarding the development of the pressure ulcer and redness to (Patient #5's) coccyx after completion of the early morning observation rounds with the night nurse.

The 03/13/13 7 AM-3 PM shift Daily Nursing Assessment/observation record timed at 08:15 AM reflected, "Skin assessment done...night nurse reported reddened area to the buttocks, pressure area about 6-7 cm (centimeters) noted to the left hip and is oval in shape. The pressure area is a stage I, no open areas...coccyx area is reddened and 2 blisters noted (not measured) at 10:00 AM...Dr paged...medical nurse practitioner assessed and determined no blisters to the coccyx...pressure area to left hip..."

The Physician's order sheet dated 03/13/13 timed at 11:50 AM reflected, "Calmoseptine cream to buttocks/perineum apply with each diaper change...turn every two hours...duoderm/tegaderm...cover left hip pressure area...change when dressing falls off..."

The 03/13/13 11-7 shift Nursing Progress Note timed at 23:00 PM reflected, "Late entry 03/13/13 at 06:00 AM...state staff informed nurse of left hip pressure area...looked at patients bottom...barrier cream to both sides of bottom and coccyx area...told MHT's (Mental Health Technicians) to make sure patient is turned every two hours..."

On 03/13/13 at 10:00 AM Hospital Staff #4 was interviewed. Hospital Staff #4 stated all the nursing staff are aware dependent patients are to be repositioned every two hours and nursing staff are supposed to monitor patient skin.

The policy entitled, "Charting in the Medical Record" with a revision date of 06/2010 reflected, "Clinical notes must reflect ongoing care and response of the patient...any incident or special occurrence will be charted when it occurs..."

Based on observation, interview and record review the infection control officer failed to provide a system to identify, report, investigate, control and avoid sources and transmission of infections and communicable diseases in that

1) Unsanitary conditions and surfaces difficult to sanitize were observed in patient care areas.
2) Facility staff failed to adhere to acceptable standards of hand hygiene prior, during, and after providing patient care to 1 of 1 patient (Patient #5).

Findings included:

1) Observations in the patient accessible gymnasium on 03/12/13 at 10:40 AM reflected the floor was soiled with small rubber pieces, dust particles, and some black residue. A dried up piece of gum was stuck to the floor. Three floor tiles were broken. The green kickboard on the Gymnasium's north side was loose. Hospital Personnel #5 agreed that the gymnasium was "dirty."

The patient luggage room floor was soiled with multiple candy wrappers and sticky papers on 03/12/13 around 10:50 AM. Two bags and suitcases were observed on the floor as well as nail clippers and a cosmetic bag. An electric wheel chair was covered with a stained towel. Hospital Personnel #4 stated at that time that the luggage's room was "not on a cleaning schedule."

On 03/12/13 at 11:10 AM, the soiled linen room was observed with two housekeeping carts with yellow mop buckets. Water was observed in one of the mop buckets. The housekeeping carts were soiled with grime and dust. Upon surveyor request, Hospital Personnel #24 took a moist paper towel and wiped down part of the cart which left the paper towel brown stained.

The Hoyer patient lift in the hospital's clean linen room was observed with dust particles on 03/12/13 around 11:30 AM. Hospital Personnel #4 agreed the patient equipment was dusty.

The nurses' station on the hospital's Adult 2 patient unit was observed with a 2 inch by 2 inch hole on 03/12/13 at 12:30 PM. The table in the patient day room was warped and had two holes exposing porous wood fill material difficult to sanitize.

The hand sanitizer container in the hallway between patient units was observed empty on 03/12/13 at 12:39 PM.

On 03/14/13 at 12:14 PM a table on the hospital Adult 1 patient unit was observed to have the rubber sealant come off around the edge of the table exposing porous wood fill material difficult to sanitize.

The findings were confirmed by Hospital Personnel #3 and Hospital #12 on 03/14/13 around 12:30 PM.

2 ) On the hospital gero psychiatric unit, Hospital Personnel #10 was observed providing perineal care to Patient #5 on 03/13/13 at 07:10 AM using the same wet wipe twice. Wearing the same gloves as during perineal care, Hospital Personnel #10 combed Patient #5's hair and touched the patient's face without change of gloves or hand washing. Hospital Personnel #13 who assisted Hospital Personnel #10 during Patient #5's perineal care proceeded to touch patient care objects including the wipe container, patient bed, linens, and wheel chair without taking the gloves off and/or performing hand hygiene.

Hospital Personnel #22 was observed on 03/13/13 around 07:31 AM to wash hands in Patient #5's bathroom for five seconds and used toilet paper to dry hands. Small pieces of toilet paper were observed on Hospital Personnel #22's hands upon leaving the bathroom.

Hospital Personnel #13 was observed on 03/13/13 around 07:35 AM washing hands for four seconds and stating, "I am going to wash hands outside." Personnel #13 left Patient #5's room and care unit, and unlocked two doors to enter the soiled utility room in the hallway between patient units. Personnel #13 was observed washing hands for six seconds and leaving the utility room without drying hands.
Findings were reported to Hospital Personnel #3 on 03/13/13 around 8 AM. No answer was given.

Hospital Policy IC100.72 revised 06/2010 reflected the "Role of the Employee...[to] wash hands frequently using proper hand washing techniques: Before and after any patient contact..." and recommended to ...continue rubbing hands for 15-20 seconds...[and] dry your hands using a paper towel or air dryer..."

Record review of the hospital infection prevention reports dated 09/2012, 10/2012, 11/2012, 12/2012, and 01/2013 reflected one hospital acquired genitourinary infection each month.

During an interview on 03/14/13 around 3 PM, Hospital Personal #4 agreed that three out of five patients with hospital acquired urinary tract infections were treated on the hospital's gero psychiatric unit.

The Centers for Disease Control (CDC, 2013) warned "Infections that patients get in the hospital can be life-threatening and hard to treat. Hand hygiene is one of the most important ways to prevent the spread of infections" and recommended "Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: before patient contact; after contact with blood, body fluids, or contaminated surfaces (even if gloves are worn)." The CDC recommended hand washing before and after patient contact and removing gloves (http://www.cdc.gov/HandHygiene/download/hand_hygiene_core.pdf) and advised 40 to 60 seconds for the hand washing procedure including drying hands with paper towels (http://www.who.int/gpsc/5may/How_To_HandWash_Poster.pdf).