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Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by:

1. Failing to ensure the RN initiated post operative physician orders for 1 out of 1 patient (Patient #7) reviewed for initiation of post operative orders out of a sample of 7 patients.
2. Failing to ensure a patient's wound was assessed every shift according to hospital policy for 1 (Patient #3) out of 2 patients' wound assessments (Patient #1 and Patient #3) reviewed for inpatient wound care out of a sample of 7 patients.
3. Failing to ensure a physician's order for warm compresses, to a wound, every 2 to 3 hours, was implemented and failure to ensure a consult for wound or Ostomy Nurse was implemented in a timely manner for Patient #3. Findings:

1. Failure to initiate post operative physician orders

Review of the hospital's policy for Physician's Orders, Policy Number 18.l0, revealed in part, Process for written orders: 1. The physician will write an order on the physicians order sheet for the correct patient. 2. Nursing service personnel (ward clerk, unit tech, nurse, etc.) will electronically enter the orders and note the transcription on the written order. 3. Orders should be reviewed and acknowledged by the nurse. This should be done by written signature and date on the physician order sheet, and acknowledgement of orders electronically.

Review of Patient #7's medical record revealed she was 42 year old woman admitted to the hospital on 3/06/16 for worsening of a burn to her left palm. Further review revealed she had surgery on 3/07/16 for a left hand abscess and was returned to her hospital room after the surgery at 7:40 p.m. on 3/07/16.

Review of Patient #7's post operative orders dated 3/07/16 (no time documented) revealed an order to conduct neurovascular checks with vital signs on the left hand. Further review of the patient's post operative orders revealed an order for VTE (Venous Thromboembolism) Mechanical Prophylaxis with SCD's (Sequential Compression Device) and TED's (Thrombo Embolic Deterrent). Review of the EMR (Electronic Medical Record) revealed there was no documentation these interventions were implemented as ordered by the physician.

An interview was conducted with S2PI on 3/09/16 at 8:00 a.m. She reported due to the surgeon writing his orders and placing the post operative orders on the patient's paper chart, the orders were missed by the unit clerk and the nurse. She went on to report the nurses are accustomed to most of the physicians entering their orders into the computer. She reported the post-operative orders were implemented when the surveyor discovered the error on 3/08/15 at 4:00 p.m. (approximately 16 hours after the patient's surgery).S2PI further reported the paper medical chart should have been checked (by the night nurse), but was not and a 24 hour chart check should have been done to ensure all orders were implemented.

2. Failure to assess a wound every shift per hospital policy

Review of the hospital 's policy for Pressure Ulcer Prevention and Wound Care, Policy Number 22.01, with the latest revision listed as 2/15, revealed in part, Assessment: On admission and every shift the RN/LPN will complete a full head to toe physical assessment of the patient's skin condition. A RN will reassess the patient every 24 hours or more often if needed. Upon identification of a wound, the nurse will be responsible for notifying the physician and completing the following: 1. Measurement will be done on admission, and weekly, or as needed based on a change in patient wound status ...2. Documentation: All open wounds, including pressure ulcer, should be documented on the admit assessment form, and every shift on the skin assessment flowsheet or beginning of shift assessment. If skin is abnormal with no open wound, document abnormal findings in the beginning of shift. Document open wound assessment as follows:
Wound bed-color, type of tissue (i.e. granulation, slough, eschar). Exudate-type, color. Odor, amount, (i.e. serosanguinous, serous, purulent, bloody).
Periwound-describe surrounding skin (i.e. callous, macerated, erythema)
Pain- presence of absence of, type, and interventions
Extent of wound (full or partial thickness) or stage if wound is related to pressure.
Review of the medical record for Patient #3 revealed he was a 45 year old man admitted to the hospital on 3/03/16 for facial cellulitis above the right eye. Further review of the medical record revealed on admission (3/3/16 at 5:08 p.m.) the wound was assessed as right eye brow has a circumferential area with scant amount of yellow drainage, moderate swelling, right eye lid swollen, difficult to open eye, able to see out of eye, has dx (diagnosis) of cellulitis.
Review of the Physician 's Orders on 3/5/16 at 11:37 a.m. revealed an order to send biopsy for Histopathology, rule out bacterial pyoderma verses deep fungal verses atypical mycobacterium. Also there was an order to apply bactroban to site (including biopsy site) BID (twice a day) with bandage. Review of the Skin Assessment Flowsheet dated 3/5/16 revealed a skin biopsy was conducted on 3/5/16 at 10:57 a.m. Further review of the EMR (Electronic Medical Record) revealed no complete assessment of the wound from 3/5/16 through 3/7/16 when the surveyor reviewed the record.
An interview was conducted with S2PI on 3/07/16 at 3:00 p.m. She reported, after review of the medical record, there was no complete assessment of the patient's wound from 3/5/16 until present (3/07/16 at 3:00 p.m.).
3. Review of the medical record for Patient #3 revealed he was a 45 year old man admitted to the hospital on 3/03/16 for facial cellulitis above the right eye.
Review of the physician's orders for 3/03/16 at 6:18 p.m. revealed an order for Wound or Ostomy Consult-Nurse on 3/03/16 at 6:18 p.m. Further review of the physician orders revealed an order, dated 3/6/16 8:19 a.m., to resume warm compresses to right side of face for 20 minutes every 2 to 3 hours.
Review of the medical record revealed as of 3/07/16 the patient had not had a wound or ostomy nurse consult and the warm compresses to the right side of the patient's face had not been implemented every 2 to 3 hours as ordered.
An interview was conducted with S2PI on 3/07/16 at 3:00 p.m. S2PI revealed the wound consult had not been done because there was only one wound care nurse at the hospital and she was in training on another unit one day and then she was off of work for three days. S2PI went on to state the hospital did not have a policy for the length of time in which a nurse wound consult should have been implemented. She verified 4 days was too long before a consult was conducted. S2PI also verified with review of the patient's medical record that the order for wound compresses to the patient's face every 2 to 3 hours were not implemented/documented in the medical record every 2 to 3 hours as ordered.

Based on record review, observation and interview, the hospital failed to ensure the Infection Control Officer implemented a system for controlling infections as evidenced by:
1. failure to ensure visitors and staff wore appropriate personal protective equipment while in a patient's room who was in contact isolation for 2 (Patient #3 and Patient R1) out of 2 patients observed for correct isolation procedures.
2 failure to ensure the computer stations were clean for 6 out of 6 computer stations (Rooms a-f) observed for cleanliness in hospital rooms deemed ready for an admission of a new patient.
3. failure to ensure a clipboard (which was in use by patient caregiver) was placed on a clean surface when entering a patient's room as evidenced by a clipboard being placed on the floor in the hallway next to a patient's room. Findings:

1. Contact Isolation

Review of the hospital policy for Contact Precautions, Number 6.24 revealed in part, ...3. Gowns are indicated when entering the room due to contact with the patient, environmental surfaces or items in the patient's room or if the patient has:
a. Incontinence
b. Diarrhea
c. Colostomy
d. Ileostomy
e. Wound Drainage not contained by a dressing

Patient #3
An observation was conducted on 3/9/16 at 9:45 a.m. of S9Housekeeper cleaning Patient #3's room without a gown on to protect her clothing after the patient was discharged from the hospital. A contact isolation sign was observed on the door to the patient's room.

Review of the medical record for Patient #3 revealed he was admitted to the hospital for facial cellulitis. Further review of the patient's medical record revealed the patient's wound was draining.

An interview was conducted with S9Housekeeper on 3/09/16 at 9:45 a.m. She reported she did not wear a gown when she cleaned a room if a patient was on contact isolation, but she did wear a gown when the patient was on airborne isolation.

An interview was conducted with S8ICO on 3/09/16 at 11:00 a.m. She reported S9Housekeeper should have been wearing a gown when cleaning Patient #3's room because he had been in contact isolation prior to his discharge from the hospital.

Patient R1

An observation was conducted of Patient R1's room with a Contact Isolation sign on the outside of the room. With further observation two visitors were noted to be sitting next to the patient's bed without a gown protecting their clothing.

An interview was conducted with S10RN on 3/09/16 at 10:30 a.m. She reported the visitors were actually guards and since they were not touching the patient they did not have to wear gowns while in a patient's room who was in contact isolation.

An interview was conducted with S8ICO on 3/09/16 at 11:00 a.m. She reported the guards needed to wear gowns while they were in the patient's room because of the chance of their clothing becoming environmental contaminated.

2. Computer stations in Patient Rooms

Review of a Memo sent out on 6/28/13 to all nursing staff, provided to the surveyor by S2PI, revealed in part, Computer in patient room guidelines: In semiprivate rooms scanners and scanner cords are to be cleaned with individual disposable wipes after each medication administration episode. In all rooms, scanners and scanner cords are to be cleaned with disposable wipes if scanner becomes contaminated. At discharge the outside of the computer cabinet, the work space, keyboard, finger printing scanner, scanner and scanner cord are to be cleaned with a disposable wipe. Monitor and screen may be cleaned with a disposable wipe.
An observation was conducted on 3/07/16 from 10:30 a.m. to 11:30 a.m. of the following rooms' computer stations: Rooms a, b, c, d, e, and f . Lifting up of the computers' keyboards from the stations revealed numerous needle caps, vial caps, dust and papers.

An interview was conducted with S2PI on 3/7/16 at 11:00 a.m. S2PI verified the findings and reported it was nursings' responsibility to clean the computer stations. She further reported since the computer stations are locked housekeeping does not have access to the computer stations to clean them.


3. On 3/09/16 at 9: 45 a.m. a clipboard was observed propped up in the hallway, on the floor, next to a patient's room on the second floor.

An interview was conducted with S2PI on 3/9/16 at 11:45 a.m. She reported the clipboard belonged to S11PTA. He reported to S2PI he didn't want to bring the clipboard into the patient's room so he propped the clipboard on the floor in the hallway next to the patient's door. S2PI further reported it was not appropriate for the PTA to place the clipboard on the floor.