HospitalInspections.org

REVISED VERSION
Based on findings from document review and interviews, in 3 of 17 medical records (MRs) reviewed (Patients A, E, and G), the nursing care provided and/or documentation in connection with skin care did not meet generally accepted standards. Also, in 1 of 17 MRs reviewed (Patient N), nursing did not document why a medication ordered on an "as needed" (PRN) basis was given.

Findings include:

-- Per review of Patient A's MR, this patient was admitted on 1/3/14 to the Intensive Care Unit (ICU) from the Emergency Department (ED) with a right perinephric hematoma and renal failure. The patient was on bedrest from 1/3/14-1/7/14 with documented independent ability to turn himself in the bed. The patient's risk for developing a pressure ulcer was assessed daily using the Braden Scale assessment and scoring tool. Throughout Patient A's hospitalization (1/3/14-1/14/14) his Braden scores ranged from 17 - 21, i.e., not at risk to mild risk, respectively.

On 1/11/14, a physician ordered Calmoseptine (an over-the-counter multipurpose moisture barrier ointment) to be applied to the peri area twice a day and PRN. Nursing recorded application of Calmoseptine on the medication administration record (MAR) on 1/11/14, 1/12/14, 1/13/14, and 1/14/14. However, until 1/13/14 the nursing progress notes lacked a description of the affected skin area (e.g., specific location, appearance, and size) and the reason the Calmoseptine was needed.

Further, on 1/13/14 nursing documentation on a Braden Skin/Wound Assessment form in the MR indicated that the Calmoseptine was being applied to the patient's "gluteal" area versus the peri area specified in the physician order. On 1/14/14 nursing documention in this same section of the MR indicated the Calmoseptine was being applied to the "buttocks" area. Also, the nursing documentation continued to lack a description of the size and characterisitics of the affected skin area.

-- Per review of Patient E's MR, this 92 year old was admitted 7/11/14. A nursing assessment on 7/12/14 notes excoriation on the gluteal coccyx, documentated as stage 1. The MR does not contain any further mention of this excoriation or of notification to the patient's physician.

Per interview with RN #16 on 7/16/14 at 10:30 am, Patient E did not currently have any excoriation.

-- Per review of Patient G's MR, this 72 year old was admitted on 7/11/14. A nursing assessment on the same day described "a small crack" in between buttock cheeks, and ecchymotic areas. The ecchymotic areas were not described in detail regarding number, sizes and locations. As of 7/16/14, the MR lacked further description of these alterations in skin intergrity and indication the patient's physician was notified.

Observation of Patient G on 7/16/14 at 3:00 pm revealed she had a slit approximately 12 cm in length in between her buttocks (in head to toe direction). Additionally, there was a large dark purple ecchymotic area on the patient's left chest area. Again, none of these findings were described in the MR.

--The facility's P&P titled "Skin Care Policy and Procedure," dated 3/18/13, directed nursing staff to notify the physician regarding any stage pressure ulcers, on admission or at any time noted in the hospital, and to document this notification on the medcial record. It also required nursing staff to document wound assessments and management on the daily Braden Scale form found in the electronic MR.

-- During interview with the Nurse Manager for Allen Calder (AC) 3/Coronary Care Unit (CCU) on 7/16/14 at 3:00 pm, the above findings were acknowledged.

--Per review of Patient N's MR, on 7/12/14 a physician wrote an order for acetaminophen 650 mg orally every 4 hours PRN mild pain/fever greater than or equal to 101 degrees Fahrenheit (F). According to the MAR, the patient received a dose of acetaminophen on 7/12/14 at 8:59 pm, despite lack of indication for the medication in the nursing progress notes, i.e., mild pain or fever. The only temperature recorded in the MR around this time was 99.4 degrees F, rectally, at 8:30 pm. Also, nursing documented "no sign of pain" at 9:00 pm on 7/12/14 and at 12:00 am on 7/13/14.

Based on findings from document review and interviews, telephone and verbal orders were not complete and/or authenticated within 48 hours in 2 of 17 medical records (MRs) reviewed (Patients H & I ).

Findings include:

-- Per review of the hospital policy and procedure titled "Medication Management Policy," last revised 5/15/12, it indicated that the nurse receiving telephone or verbal orders will affix a yellow "Sign and Date" flag to the document to assist the physician to endorse the order as soon as possible but within 48 hours.

-- Per review of Patient H's MR on 7/15/14 at 3:30 pm, it contained a telephone order provided by Physician #1 for transfusion of 1 unit of packed red blood cells that was neither dated nor timed. A 24 hour check of the order was documented on 7/12/14 at 0600, providing indication the order was still not signed and dated by the physician 5 days later (as of 7/15/14).

-- Per review of Patient I's MR on 7/15/14 at 3:45 pm, it contained the following 6 telephone / verbal orders that were not signed within 48 hours:

On 6/25/14 at 1530, a telephone order by Physician #2 for Heparin per protocol remained unsigned 20 days later.

On 6/26/14 at 1842 , a telephone order by Physician #3 to "Hold IV Vanco until patient is seen by Dr. ..." remained unsigned for 19 days.

On 7/5/14, the following two telephone orders provided by Physician #4 remained unsigned for 10 days: one order at 0845 for 40 meq KCL now via PEG tube, and another order at 1830 for Tylenol 650 mg oral now per PEG tub, consult ID, 5oo ml Bolus of 0.9 % Normal Saline now, and cooling blanket PRN for temp > 103 degrees Fahrenheit.

On 7/8/14 at 1030, a verbal order by Physician #5 for "Attempt CPAP per weaning protocol daily" remained unsigned 7 days later.

On 7/12/14 at 1805, a verbal order by Physician #6 to "Hold daily CPAP trials for now" remained unsigned for 3 days.

--During interview with the Clinical Educator of Oncology on 7/15/14 at 3:30 pm and 3:45 pm, the above findings were acknowledged.

Based on findings from observations and interviews, the hospital did not provide pharmaceutical services in accordance with current standards of professional practice. Specifically, 1) expired medications were available for patient use and/or were stored in an area that was not secure, and 2) nursing staff (registered nurses / RNs #6, #9, #10, #12, and #13 thought opened multi-dose medication vials were okay to use for 30 days (versus the standard 28 days).

Findings pertaining to (1) above include:

-- During tour of the hospital's Behavioral Health Unit's medication room on 7/15/14 at 10:30 am, 4 expired Fleets enemas were observed stored in a double-locked cabinet, three with expiration dates of 4/2014 and one with an expiration date of 3/2014. This was confirmed during the tour with RN #18.

--During tour of the hospital's Allen Calder (AC) 2 East Unit on 7/16/14 at 10:00 am, Nitro Stat (nitroglycerin sublingual) medication which had an expiration date of 10/2012 was observed stored in a cabinet in an open room located behind an unmanned nursing desk. This area was accessible to non-nursing staff. This was confirmed during the tour with the Clinical Educator for AC2.

Findings pertaining to (2) above include:

-- During interviews with five nursing staff, i.e. on 7/15/14 at 2:05 pm with RN #6, and on 7/16/14 with RNs #9, #10, #12, and #13 at 11:45 am, 1:35 pm, 9:55 am, and 12:00 pm, respectively, they each indicated open multidose medication vials could be available for patient use for up to 30 days after the vial was opened, not the 28 days per generally accepted standards for pharaceutical services or the hospital's policy and procedure.

-- The hospital P&P titled "Medication Management Policy," dated 5/5/12, indicated / required that multidose medication vials be discarded within 28 days of opening.

Based on findings from observations and interview, the condition of the physical plant and the overall hospital environment was not maintained in a manner that ensured cleanliness for the safety and well-being of patients.

Findings include:

-- Per observations on 7/16/14 at 9:45 am on AC 2 West, in the Dirty Utility Room approximately 1/4 of the floor (including directly in front of the trash can) was covered with a dried red sticky substance.

-- Per observations on 7/16/14 at 10:00 am on AC 2 East, the IV (intravenous) Fluid Room (secured room used to store needles, syringes, IV solutions and other clean supplies) had multiple holes in the walls making them not smooth and easily cleanable. Also, the IV Fluid Room had paper trash covering 1/3 of the floor space, and the shelving unit was covered with a very thick layer of dust.

-- The above findings were observed with the Clinical Educator for AC2 during the tours of the AC 2 Units on 7/16/14 at 9:45 am and 10:00 am.

Based on findings from observations and interview, facility staff did not follow generally accepted standards of infection control practices in connection with contact precautions. Also, expired patient supplies were available for patient care.

Findings include:

-- Per observations on 7/15/14 at 12:15 pm on the Allen Calder (AC) 3 unit, Intern #1 was observed exiting a patient's room that had a posted sign for contact precautions. Intern #1 did not first remove his/her yellow isolation gown and was not wearing gloves. Intern #1 walked into the hallway to the clean linen cart to retrieve clean linens. He/she then re-entered the same patient room with the same yellow isolation gown, and did not wash or sanitize his/her hands or apply gloves.

A sign for contact precautions was clearly posted outside the door of the patient room with the following instructions:
1. Wash hands with soap and water or use waterless hand sanitizer before applying gloves.
2. Wear gloves at all times, remove gloves before leaving room and wash hands with soap and water or waterless sanitizer.
3. Wear gowns when entering patient room and remove before leaving the room.

-- During interview on 7/15/14 at 12:15 pm with Intern #1, he/she acknowledged not wearing gloves in the room and exiting the room without removing the yellow isolation gown. Intern #1 didn't think he/she had to disgown as he/she was just observing the nurse provide patient care and was not providing direct patient care.

-- The findings above were confirmed in the presence of RNs #1 and #3.

-- According to the nationally recognized 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (available at http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf>), page 70: "Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in the transmission through environmental contamination."

-- Further, during tour of the hospital's AC 2 West Unit on 7/16/14 at 9:50 am, the following expired blood specimen vials were observed in the Clean Utility Room to be available for patient use:

* 3 purple topped vials with expiration dates of 1/2014, 3/2014, & 4/2014
* 2 green topped vials with expiration dates of 11/2013 & 3/2014
* >10 blue topped vials, all with expiration date of 5/2014.

This finding was confirmed during the tour with RN #19, Clinical Educator for AC2.