HospitalInspections.org

Based on a review of the facility's Quality Assessment and Performance Improvement Program (QAPI) the facility failed to identify all areas of the hospital where patients might be at risk for similar problems (developing pressure ulcers), failed to identify all areas where expired needles might be used and failed to implement preventive actions which the facility found effective in other parts of the hospital.

The findings include:

On 2/6/15 during an interview with Staff Member #28 the QAPI process for the facility was reviewed. Three cases the facility had documented as a review of adverse patient events or close calls were reviewed. The cases selected were related to none available equipment, pressure ulcers and the use of expired needles.

Staff Member #28 acknowledged they failed to identify all areas of the hospital where the events could occur related to pressure ulcers and expired needles.

Staff Member #28 also acknowledged the facility failed to implement preventive actions they found effective in all areas of the facility.

Based on document review and interview the facility failed to ensure the medical staff followed the medical staff bylaws concerning documentation of an ordered consult for 1 of 20 patients, Patient #9. The facility also failed to ensure physicians who are paged by the nursing staff or operator respond timely for 1 of 20 patients, Patient #10.

The findings include:

On 2/3/15 a review of Patient #9's medical record was conducted with Staff Member #6. Patient #9 was a 77 year old admitted on 11/1/14 at 03:39 with a diagnosis of Pelvic and Lumbar fracture due to a fall. The attending physician ordered an orthopedic consult on 11/1/14 at 08:51.

The attending physician electronically signed on 11/1/14 at 14:52 that he discussed Patient #9's fractures with the orthopedic physician. The attending documented "(Name of Orthopedic physician), and he feels that nothing really needs to be done. (He/She) Patient #9 can weight bear as tolerated. No further follow up is required with orthopedics."

There is no evidence in Patient #9's medical record that the orthopedic physician reviewed the x-rays. The consulted orthopedic physician did not document in Patient #9's medical record.

Staff Member #2 stated, "Medical records does not require the consulting physician to make a notation in the medical record if the attending has documented they discussed the case and what the plan is."

Patient #10 was admitted on 1/5/15 and discharged on 1/9/15 with a diagnosis of fever acute and interstitial pneumonia. The attending physician placed an order for tube feedings on 1/5/15 at 07:37. On 1/8/15 at 12:00 the nurses' notes document Patient #10 did not want the Kangaroo pump used for tube feeding because Patient #10 did not trust the machine. Patient #10 also declined bolus tube feeding because they made Patient #10 nauseous. Patient #10 requested a gravity tube feeding.

Patient #10's attending physician was paged on 1/8/15 at 16:00 to make him aware of Patient #10 issues related to tube feedings. The attending physician did not respond to the page and the physician on call was paged at 16:45. The physician on call did not respond. Patient #10's attending responded at 18:12.

Staff Member #28 provided a copy of the Medical Staff Professional Practice Policy approved on June 17, 2011 and revised on 1/24/14. Page 15 Section G states, "Consultations shall show evidence of review of the patient's record by the consultant, pertinent findings on examination of the patient, the consultant's opinion and recommendations. This report shall be made a part of the patient's record. All request for consultation shall be completed and documented within 24 hours."

Page #17 Section A #2 states, "Each practitioner on call is responsible for a timely response to pages. Timely responses is defined as:
a. Emergent pages on phone calls will be responded to within five (5) minutes of receiving the pages or call;
b. All other pages from the emergency department or hospital units will be responded to within fifteen (15) minutes.

Based on document review and interviews, the facility nursing staff failed to ensure a plan of care for 1 patient, Patient #10 was developed and kept current and followed as necessary as related to skin assessments, intake and output and documentation and treatment of pressure sores.

The findings include:

Patient #10 was a 80 year old who was admitted 5 times between 11/14/14 and 01/25/15. Patient #10 was initially admitted on 11/14/14 with a diagnosis of cervical myelopathy, likely on basis of prominent disk protrusion at C4-5 and C3-4 and radiculopathy on basis of severe multilevel foraminal stenosis. Patient #10 had an anterior cervical discectomy and fusion (ACDF) performed on 11/14/14.
Admission and discharge dates are as follows:
First admission 11/14/15 Discharge 11/25/14
Second admission 11/26/14 Discharge 12/8/14
Third admission 01/04/15 Discharge 01/09/15
Fourth admission 01/16/15 Discharge 1/23/15
Fifth admission 1/25/15 Discharge 1/30/15
First Admission:
The nursing notes for 11/18/14 at 14:30 Tube feeding ordered - The first 2 feeding pumps found did not work, a third feeding pump was located and at 18:17 the tube feeding was started. There was four hours between order and first attempt for a tube feeding before Patient #10 received the tube feeding.
The nursing notes for 11/24/14 at 08:00 Erythema/rash to buttock, 20:00 Incision on neck, right forearm red, cream applied to buttock, sacrum and coccyx. There is no indication Enterostomal Nurse was notified to assess wounds on buttock, coccyx. Patient #10 was discharged home on 11/25/14.
Second Admission:
On the 11/26/14 admission A stage II pressure ulcer to the sacrum is noted by Emergency Department (ED) nurse. This triggers an assessment to the Enterostomal Nurse. The attending physician cancels the order then reorders the consult within minutes. On 11/28/14 the nursing notes at 08:00 indicate a left hip dressing of telfa with Bio-Occlusive as well as the sacral wound.
On 12/03/14 at 08:00 the sacrum wound measures 2 cm X 1 cm with an open area to inner buttock, no other wounds are noted. At 20:00 bruising on bilateral upper extremities and right hand are documented.
On 12/04/14 at 08:00 and 20:00 there is no documentation about any wound other that the anterior neck. It is not until 12/5/14 at 20:00 that a nurses' note about Patient #10's wounds other than surgical is noted. And that note states, "Left hip with steri-strips bruising no signs or symptoms of infection".
The note on 12/06/14 at 20:00 indicates a Left hip incision with steri-strips, Left shoulder abrasions. No other notes related to wounds. Patient #10 did not have a left hip incision documented by a physician.
On 12/07/14 at 20:00 a Stage 2 pressure sore on Left buttock, moisture barrier cream applied, Right lower extremity weeping clear yellow liquid. There is no documentation as to what care was provided for the right lower extremity "weeping clear yellow liquid."
Patient #10's pressure wounds, bruising, weeping extremities and "left hip incisions" were never seen and assessed by the Enterostomal Therapy Nurse during this admission. The nursing staff on the unit(s) did not follow through with the plan of care to investigate why.
Staff Member #29 and 30 were interviewed on 2/4/15 at approximately 9:50 A.M. Staff Member #30 stated, "We see patients with wounds. When nursing make a note about a pressure sore the computer will kick out a consult to us to see the patient if it is a stage 2 or above. Nursing could call us regarding a wound that is not a stage 2 and ask us to evaluate the wound. We try to do all consults within 24 hours but we have up to 72 hours to see the patient. We are not available on Saturday or Sunday and Holidays, we were not here on Thanksgiving. We try to see every patient at least once per week to assess the area and if needed to change the care of the wound if not healing. I do not know why this patient was not seen."
Staff Member #6 stated, "The Stage 2 pressure sore diagnosis in the ED should have triggered a wound consult."
Third Admission:
Patient #10 was seen on 1/5/15 at 11:19 and assessed by Enterostomal Nurse (ET nurse). The ET nurse's note stated, "assessment of sacral site. Pt. (Patient #10) has a aspen collar on due to neck fusion surgery. Pt. able to turn for assessment with minimal assistance. Sacral site is noted to have an unstageable area with yellow eschar that is 5 X 3.5 cm in size. Also noted at the 7 o'clock area of the peri-wound skin is a dark purple site suspected to be a DTI (Deep Tissue Injury) approx 2 X 2 cm. Assisted pt with repositioning; Pt is on a versa care air bed. Tried to do teaching regarding pressure relief and pat not receptive at this time as He/She is focused on eating. Discussed with nursing pt's wants. P: Start Santyl BID to sacral site and frequent repositioning."
Healthline "What causes eschar? 5 possible conditions" Written by Rachel Nall and medically reviewed by George Krucik, MD, MBA published on July 19, 2012 states eschar is typically tan, brown or black. A wound with eschar often signals a more advanced wound, typically a stage III or stage IV.
The American Association for Long Term Care Nursing "Ask Wound Coach" states, "Slough is usually lighter in color, thinner and stringy in consistency; Color - Can be yellow, gray, white, green, brown; Eschar - usually darker in color, thicker and hard consistency black or brown in color."
The National Pressure Ulcer Advisory Panel (NPUAP) describes a Deep Tissue Injury (DTI) as "a unique form of pressure ulcers." NPAUP's proposed definition is "A pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise. These lesions may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment." NPAUP's treatment recommendations for DTI with intact skin are: Remove the cause of the pressure, shear and/or friction. Provide appropriated redistributing surfaces for bed and chair. Keep skin intact. Provide a moisture barrier for skin sealant. Observe at least daily for any changes and treat appropriately. Provide education to patient, healthcare decision maker and care-giver regarding anticipated changes/decline.
Staff Member #2 stated she contacted Staff Member #30 who reported eschar is either brown or black and slough is yellow, tan or gray.
There was no indication a treatment for the DTI was prescribed by the ET nurse.
01/08/15 - 08:00 "wound care completed to sacrum this am, unstageable wound to sacrum, 2 smaller wounds to bilateral upper buttock"; 12:00 Patient #10 declines to use the Kangaroo Pump for tube feeding stating He/She does not trust the pump and also declines bolus tube feeding due to making He/She sick; 16:00 the attending physician was paged regarding Patient #10's refusal. There was no response and the physician on call for the attending physician was paged at 16:45. 18:04 Patient #10 requested a gravity tube feeding and is informed that is not available in the hospital; the attending physician returned the call at 18:12. 20:00 Pressure ulcer to sacrum, coccyx, bilateral buttock, multiple Stage II (pressure ulcers) and 1 unstageable to sacrum.
On 2/4/15 at approximately 11:45 A.M. Staff Member #10 was interviewed and stated, "Yes, we can do a tube feeding by gravity here. But this the only one I have seen in 7 years." Staff Member #9 was interviewed at approximately 2:40 P.M. and stated, "No we cannot do gravity tube feedings with the type of tubing we have. The tubing has to be fed through a pump so the tubing can be stretched to allow the feeding to go through." The staff can not agree on what they can provide for or not provide for a patient.
01/09/15 - 08:00 Stage II to sacral area covered with dressing no drainage. The documentation of stage of the pressure ulcers did not match the documentation from the ET nurse.
Patient #10 was discharge home on 01/09/15.
Fourth Admission:
Patient #10 was admitted for a 4th time on 01/16/15 via the ED with a diagnosis of SIRS (systemic inflammatory response syndrome) and dehydration; ED notes at 20:43 document 2 pressure ulcers to the buttock, dressing dry and intact, ET consult generated; 23:30 wants tube feeding with medications, no food since lunch;
The nursing notes indicate the following: 01/17/15 at 08:00 No skin assessment noted; 20:00 dressing to sacrum dry and intact.
01/18/15 - 08:00 no skin assessment; 20:00 dressing to sacrum dry and intact. There is no indication the dressing on the sacral wound was changed so as to assess the severity of the pressure sore on the sacrum.
01/19/15 - 08:00 dressing to unstageable pressure ulcer; 20:00 pressure ulcer
Approximately 72 hours pass before Patient #10's pressure ulcer(s) are assessed by the ET nurse. On 1/19/15 at 15:55 Patient #10 is seen by ET nurse for first assessment this admission. ET nurses' note documents: Pt. known to ET services from previous admission, pt alert, and family at bedside. Pt (Patient); on versa care air bed. Pt able to turn in bed but needs some assistance with holding over. Dressing to sacrum soiled form previous stooling. Has unstageable PU (pressure ulcer) on sacrum 4 X 2 cm with opening through the slough covering the base of the ulcer at 0.5 cm diameter. No odor or drainage noted. There are 3 adjacent open areas, Stage II to III all <1 cm. Area thoroughly cleaned and applied Santyl to sites when covered with saline moist gauze, gauze and held with paper tape. Pt turned to L (left) side with pillows, ordered Vashe earlier to use with Santyl, P (Plan) Staff to continue Santyl and Vashe dressing. Will follow PRN (Whenever necessary). There is no indication where the other 3 pressure ulcers are located in comparison to the sacral wound.
On 01/20/15 at 08:00 the nurses' note indicates a coccyx wound is noted. There is no indication what treatment if any was provided to this wound. 20:00 pressure ulcer sacrum
01/21/15 - 08:00 wound sacrum; 12:29 speech therapy; 16:10 Patient refused assistance with CNA (Certified Nursing Assistant) to get back in bed nurse assisted; 20:00 sacrum pressure ulcer
01/22/15 - 08:00 Skin tears to left hand, wound sacrum; 09:30 skin tear to left hand cleansed dressing applied; 10:37 speech therapy MBS completed, decreased laryngeal movements, recommend NPO occasional ice chips; 13:00 scant amount of blood in right nostril; 18:00 emesis small amount of blood, PRN med for N&V given; 20:00 left hand wound, sacrum wound.
The nurses' note on 01/23/15 at 08:00 indicates scattered scars and sacrum wound. There is no documentation where the scars are.
Patient #10 was discharged on 01/23/15
Fifth Admission:
Patient #10 was readmitted on 01/25/15 via the ED with a diagnosis of SIRS and sacral decubitus (pressure sore).
The review of Patient #10's medical record revealed the following notations:
On 01/25/15 at 16:44 IV placed; 17:55 pressure ulcer stage IV sacrum, healed midline incision to back neck, total care bed, peri wound skin macerated, reposition q2h (every 2 hours) mepilex applied; 17:32 attending physician orders a Enterostomal Therapy Consult/Treatment Expedite once; 20:11 no PICC line, stage IV pressure wound; 19:45 C-collar intact, midline incision, puncture wound anterior abdomen upper left, sacrum pressure ulcer mepilex intact.
Staff Member #16 stated, "Expedite once means less than a STAT order but more than a standard order."
01/26/15 - 02:00 Fentanyl patch removed; 08:00 sacrum wound Aquacell applied wound open to air; 20:00 Sacrum stage II. There is no indication the pressure ulcer had improved to a St
01/27/15 - Stage II sacrum dressing CDI (Clean Dry and Intact); 19:37 C/O nausea, Zofran given 20:00 Stage II dressing CDI; 22:35 Jevity increased, Imodium (first documentation of tube feeding.
01/28/15 -01:15 Condom cath removed, using urinal; 08:00 pressure ulcer sacrum. There is no documentation related to the condition of wound or dressing. 15:15 New tube feeding with TwoCal; 19:43 Sleeping, feeding infusing; 20:00 PEG with dressing clean dry intact, sacrum stage II, dressing clean dry intact.
It has now been approximately 72 to 84 hours since the physician wrote an expedite once order for Enterostomal Therapy assessment.
01/29/15 08:00 pressure ulcer sacrum; 10:17 Enterostomal Therapy Focus Note: Pt seen for reassessment of sacral wound. Pt has a stage IV ulceration that was present on admission. Pt has been using Santyl and wound is starting to show pink tissue scattered to the base of the wound. Wound appears better that prior admission as slough is starting to lift. Answered family's questions and discussed with (Name of attending physician), will add Vashe to the treatment plan with Santyl. Will con't to follow as needed for care; 13:30 speech therapy; 14:03 documented intake of 1060 orally (Patient #10 can't swallow and is NPO); 18:45 feeling nauseated, PRN med given for nausea, tube feeding paused, med for nausea did not help, given med for anxiety, tube feeding restarted, pt fell asleep and when woke up continued to complain of nausea, tube feeding stopped; 19:30 tube feeding off, cont. to complain of nausea; 20:00 Stage II sacrum dressing clean dry and intact. There was no evidence of any dressingg changes to sacrum wound.
The nursing staff's assessment of the sacral wound was a stage II prior to being seen by ET and even after being seen by ET on the same day. ET assessed the sacral wound and labeled it a stage IV.
01/30/15 - 14:00 call to pharmacy to inform them the PICC line had been placed and that Patient #10 was being picked up for transfer to another facility at 16:00. Pharmacy reported the policy is to start TPN (Total Parenteral Nutrition) at 18:00. If it (the TPN) is made now (Name of receiving hospital) would discard it (the TPN). 15:56 call to on call physician at son's request. Son states (Name of Patient #10) has not had anything to eat or drink for 22 hours. On call physician states "unable to speak with son at this time because he/she is not in or near the hospital. He/She (physician on call) asked (caller) if it was anything specific he/she needed to address and (caller) told him/her the son was concerned because (Name of Patient #10) had not had anything to eat or drink for 22 hours. He/She (physician on call) told caller to let the son know that he/she addressed this concern with him (the son) earlier this morning and that the TPN and his/her (Patient #10) diet would be assessed at (Name of hospital Patient #10 was being transferred to) who would then make the determination as to his diet."
Patient #10 was NPO from 1/15/15 until discharge on 1/30/15.
The Intake and Output records for Patient #10 from 1/25/15 to 1/30/15 documented the following:
1/25/15 20:00 to 23:00 intake 335 ml (milliliters) output 200 ml = +135.00 ml
1/26/15 24:00 to 12:00 intake 1,526 ml output 3,001 ml = -1475 ml
1/27/15 05:32 to 23:44 intake 400 ml output 3,840 ml = -3,440 ml
1/28/15 02:30 to 23:00 intake 100 ml output 1,450 ml = -1,350 ml
1/29/15 01:40 to 22:34 intake 2,020 ml output 1,835 ml = +185 ml this was the only documentation of the amount of tube feeding given
1/30/15 04:30 to 05:09 intake 0 ml output 276 ml (had liquid stool which was documented as 1 ml) = -276 ml
Total documented intake 4,381 ml and output 10,602 ml for this admission leaving a negative balance of 6,221 ml
The facility policy on Tube Feeding, Adult C20.1 was provided on 2/2/15 and documents on page 3 of 4 section 6 "Documentation: Record time and amount of feeding and fluids in the Electronic Health Record. Document the patient's response to tube feeding, presence of abdominal distention, bowel sounds, vomiting, cramps or diarrhea when indicated."
Patient #10 was discharge on 01/30/15 at 16:30 to another facility.

Based on document review and interviews, the facility staff failed to ensure the plan of care for 1 patient, Patient #10 was developed and kept current and followed as necessary as related to skin assessments, intake and output and documentation and treatment of pressure sores.

The findings include:

Patient #10's medical records were reviewed for 5 admissions between 11/14/14 and 01/25/15 with Staff Member #6.
Patient #10 was a 80 year old initially admitted on 11/14/14 with a diagnosis of cervical myelopathy, likely on basis of prominent disk protrusion at C4-5 and C3-4 and radiculopathy on basis of severe multilevel foraminal stenosis. Patient #10 had an anterior cervical discectomy and fusion (ACDF) performed on 11/14/14.
The medical record contained the following notes regarding Patient #10:
11/17/14 Dietary and speech consults ordered as Patient #10 was having difficulty swallowing.
11/18/14 at 14:30 Tube feeding ordered - The first 2 feeding pumps found did not work, a third feeding pump was located and at 18:17 the tube feeding was started.
11/19/14 at 08:00 documented steri-strips in place on neck wound no other skin assessments noted, 20:00 note states, "neck wound looks as expected" , Air bed is ordered due to a concern about Patient #10's buttock, note states, "Not sure PS (pressure sore) or friction. Patient encouraged to change position."
11/24/14 at 08:00 Erythema/rash to buttock, 20:00 Incision on neck, right forearm red, cream applied to buttock, sacrum and coccyx. There is no indication Enterostomal Nurse was notified to assess wounds on buttock, coccyx. Patient #10 was discharged home on 11/25/14.
Patient #10 is readmitted on 11/26/14 via the Emergency Department (ED) and at 16:03 prior to admission the nursing assessment identifies a stage II pressure sore on the left buttock, skin proctectant and mepilex foam padding applied. The ED physician notes states under ROS (Review of systems) Skin, "Negative skin review of systems, Historian denies rash, Historian denies skin changes" and under Physical Exam Skin the physician noted, "Skin exam included findings of skin, Skin hot, dry, and normal in color." No notations of pressure sore.
The nursing assessment via the nursing staff on the unit on 11/26/14 at 16:29 indicate a Stage 2 pressure sore of sacrum. This notation of a stage 2 pressure sore in the pressure sore section of the nursing assessment triggers a consult with Enterostomal Nurse. The attending physician cancels the order then reorders the consult within minutes. At 20:00 the notes indicate steri-strips on the surgical incision of the neck and Allveyn covering to stage 2 pressure ulcer of right buttock.
On 11/28/14 nursing notes indicate at 08:00 a left hip dressing of telfa with Bio-Occlusive wound noted WNL (within normal limits) and a posterior dressing telfa covered with Bio-Occlusive Stage 2 pressure wound to sacrum. At 20:00 nursing notes the following left hip dressing of telfa with Bio-Occlusive wound noted WNL (within normal limits) and posterior dressing telfa covered with Bio-Occlusive Stage 2 pressure wound to sacrum.
On 12/01/14 the following nursing notes were reviewed 08:00 Surgical wound covered with 4X4, Hip telfa with Bio-Occlusive, Left abdominal peg tube; No notes on sacrum wound; 16:00 anterior steri-strips, peg tube site; 20:00 only note is regarding peg tube.
The nursing notes of the following dates and times were reviewed: 12/02/14 - 08:00 Allveyn dressing to sacrum, anterior neck midline steri-strips no S&S (signs and symptoms) of infection, abdominal dressing intact no drainage, no documentation regarding hip; 20:00 anterior post cervical dressing intact, peg tube site dressing in place, no documentation regarding hip or sacrum dressings; 23:42 anterior post cervical dressing intact, peg tube site dressing in place, no documentation regarding hip or sacrum dressings.
12/03/14 08:00 sacrum 2 cm X 1 cm open area to inner buttock, no other wounds noted; 20:00 Cervical collar, steri-strips incision intact; bruising on bilateral upper extremities and right hand, peg tube patent intact to mid upper abdomen. No notes of sacrum or hip.
12/04/14 - 08:00 Anterior neck steri-strips no signs of infection, redness or edema, edges approximate no drainage. No other wounds addressed (extremities, sacrum, hip); 20:00 Anterior neck dressing intact, steri-strips, posterior neck dressing dry and intact. No other wounds addressed (extremities, sacrum or hip).
12/05/14 - 08:00 Anterior cervical incision no signs or symptoms of infection, Posterior cervical with island dressing (a dressing with an absorbent material in the center and adhesive edges); No other notes on other wounds; 20:00 Anterior neck intact no signs or symptoms of infection, Posterior neck dressing dry and intact; Left hip with steri-strips bruising no signs or symptoms of infection.
12/06/14 - 08:00 anterior neck edges approximated, no drainage, Posterior neck edges approximated, no drainage; No other wounds addressed; 20:00 Left hip incision with steri-strips, Left shoulder abrasions. No other notes related to wounds.
12/07/14 - 08:00 Anterior neck open to air, edges approximated, Left hip incision open to air no drainage, no other wound notes; 20:00 incision on left lower abdomen with steri-strips moderate bruising, Stage 2 pressure sore on Left buttock, moisture barrier cream applied, Right lower extremity weeping clear yellow liquid.
12/08/14 - 08:00 anterior cervical neck with no signs or symptoms of infection, Posterior incision with island dressing; No other wounds noted.
Staff Member #29 and 30 were interviewed on 2/4/15 at approximately 9:50 A.M. Staff Member #30 stated, "We see patients with wounds. When nursing make a note about a pressure sore the computer will kick out a consult to us to see the patient if it is a stage 2 or above. Nursing could call us regarding a wound that is not a stage 2 and ask us to evaluate the wound. We try to do all consults within 24 hours but we have up to 72 hours to see the patient. We are not available on Saturday or Sunday and Holidays, we were not here on Thanksgiving. We try to see every patient at least once per week to assess the area and if needed to change the care of the wound if not healing. I do not know why this patient was not seen."
Staff Member #6 stated, "The Stage 2 pressure sore diagnosis in the ED should have triggered a wound consult."
Patient #10 was discharged on 12/8/14 to a rehabilitation hospital.
Patient #10 was arrived at the facility on 01/04/15 and was readmitted for the 3rd time on 01/05/15.
At 07:37 on 1/5/15 the physician placed an order for tube feeding and at 09:02 for a nutritional consult.
Patient #10 was seen on 1/5/15 at 11:19 and assessed by Enterostomal Nurse (ET nurse). The ET nurse's note stated, "assessment of sacral site. Pt. (Patient #10) has a aspen collar on due to neck fusion surgery. Pt. able to turn for assessment with minimal assistance. Sacral site is noted to have an unstageable area with yellow eschar that is 5 X 3.5 cm in size. Also noted at the 7 o'clock area of the peri-wound skin is a dark purple site suspected to be a DTI (Deep Tissue Injury) approx 2 X 2 cm. Assisted pt with repositioning; Pt is on a versa care air bed. Tried to do teaching regarding pressure relief and pat not receptive at this time as He/She is focused on eating. Discussed with nursing pt's wants. P: Start Santyl BID to sacral site and frequent repositioning."
Healthline "What causes eschar? 5 possible conditions" Written by Rachel Nall and medically reviewed by George Krucik, MD, MBA published on July 19, 2012 states eschar is typically tan, brown or black. A wound with eschar often signals a more advanced wound, typically a stage III or stage IV.
The American Association for Long Term Care Nursing "Ask Wound Coach" states, "Slough is usually lighter in color, thinner and stringy in consistency; Color - Can be yellow, gray, white, green, brown; Eschar - usually darker in color, thicker and hard consistency black or brown in color."
The National Pressure Ulcer Advisory Panel (NPUAP) describes a Deep Tissue Injury (DTI) as "a unique form of pressure ulcers." NPAUP's proposed definition is "A pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise. These lesions may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment." NPAUP's treatment recommendations for DTI with intact skin are: Remove the cause of the pressure, shear and/or friction. Provide appropriated redistributing surfaces for bed and chair. Keep skin intact. Provide a moisture barrier for skin sealant. Observe at least daily for any changes and treat appropriately. Provide education to patient, healthcare decision maker and care-giver regarding anticipated changes/decline.
Staff Member #2 stated she contacted Staff Member #30 who reported eschar is either brown or black and slough is yellow, tan or gray.
There was no indication a treatment for the DTI was prescribed by the ET nurse.
On 01/06/15 nurses' notes indicated the following: 08:00 Pressure ulcer sacrum; 11:55 PICC (peripherally inserted central catheter) line inserted 19:00 small amount of blood is pooled under dressing, blood on bottom edge of dressing, none on arm gown or linen, Nurse informs Patient #10's family the nursing supervisor was paged to change the PICC line dressing. There would be no IV therapy staff available until 23:00 to change the dressing. The nurse places a 4X4 on the PICC line wound and secured it with Kerlix until the dressing could be changed. 22:45 PICC line dressing changed.
Per Staff Member #16 on the general nursing units PICC line dressing are only changed by a member of the IV therapy team or the nursing supervisor if the IV therapy team is not available. The policy titled Intravenous Therapy; Central Vascular Access Devices, Use and Care provided by Staff Member #2 indicates site care is only provided by licensed nurses who have completed training and demonstrated competency.
01/07/15 - 08:00 Pressure ulcer on Sacrum; 20:00 Ecchymosis of right elbow, left hand, pressure ulcer to sacrum, buttock, left and right coccyx area. No other documentation related to treatment. Tube feeding no discomfort, Large BM (bowel movement) after suppository.
01/08/15 - 08:00 wound care completed to sacrum this am, unstageable wound to sacrum, 2 smaller wounds to bilateral upper buttock; 12:00 Patient #10 declines to use the Kangaroo Pump for tube feeding stating He/She does not trust the pump and also declines bolus tube feeding due to making He/She sick; 16:00 the attending physician was paged regarding Patient #10's refusal. There was no response and the physician on call for the attending physician was paged at 16:45. 18:04 Patient #10 requested a gravity tube feeding and is informed that is not available in the hospital; the attending physician returned the call at 18:12. 20:00 Pressure ulcer to sacrum, coccyx, bilateral buttock, multiple Stage II (pressure ulcers) and 1 unstageable to sacrum.
01/09/15 - 08:00 Stage II to sacral area covered with dressing no drainage.
There was no documentation of an assessment by physical therapy for this admission.
On 2/4/15 at approximately 11:45 A.M. Staff Member #10 was interviewed and stated, "Yes, we can do a tube feeding by gravity here. But this the only one I have seen in 7 years." Staff Member #9 was interviewed at approximately 2:40 P.M. and stated, "No we cannot do gravity tube feedings with the type of tubing we have. The tubing has to be fed through a pump so the tubing can be stretched to allow the feeding to go through."
Patient #10 was discharge home on 01/09/15.
Patient #10 was admitted for a 4th time on 01/16/15 via the ED with a diagnosis of SIRS (systemic inflammatory response syndrome) and dehydration; ED notes at 20:43 document 2 pressure ulcers to the buttock, dressing dry and intact, ET consult generated; 23:30 wants tube feeding with medications, no food since lunch;
The nursing notes indicate the following: Beginning on 01/17/15 at 00:01 PICC line present with insertion date of 1/6/15, INT present; 00:30 tube feeding started; 02:30 in bed comfortable, turned; 04:34 no distress PICC 04:00; 07:02 bolus tube feed; 08:00 No skin assessment noted; 10:31 B/P (blood pressure) 80/40 MD aware, peg tube infusing no N&V (nausea and vomiting), PICC line; 16:06 blood infusing c/o (complaining of) can't get enough air, O2 Sat at 98% (percent of oxygen concentration) in blood on 2 L NC (2 liters of oxygen via nasal cannula) Resp. (respirations) 22; 19:00 no complaints; 20:00 dressing to sacrum dry and intact. There is no indication as to the severity of the pressure sore on the sacrum.
01/18/15 - 06:30 2nd unit of blood infusing no complaints; 06:32 positive culture for MRSA in the nares; 08:00 no skin assessment; 19:00 resting quietly, receiving blood; 20:00 dressing to sacrum dry and intact.
01/19/15 - 08:00 dressing to unstageable pressure ulcer; 04:38 Patient received 2nd unit of blood, vomited X 1 feels better; 12:05 Speech therapy recommended Neuro Consult; 14:23 Vascular tech performed bilateral lower extremity Doppler - no thrombi; 14:45 assessment of PICC line cath flor (used to remove clots on end of catheter) inserted, 16:05 cath flor removed, PICC line flushed; 16:41 speech therapy swallow evaluation performed, ice chips only, NPO (nothing by mouth) status, MBS recommended; 20:00 pressure ulcer
On 1/19/15 at 15:55 Patient #10 is seen by ET nurse for first assessment this admission. ET nurses' note documents: Pt. known to ET services from previous admission, pt alert, and family at bedside. Pt (Patient) on versa care air bed. Pt able to turn in bed but needs some assistance with holding over. Dressing to sacrum soiled form previous stooling. Has unstageable PU (pressure ulcer) on sacrum 4 X 2 cm with opening through the slough covering the base of the ulcer at 0.5 cm diameter. No odor or drainage noted. There are 3 adjacent open areas, Stage II to III all <1 cm. Area thoroughly cleaned and applied Santyl to sites when covered with saline moist gauze, gauze and held with paper tape. Pt turned to L (left) side with pillows, ordered Vashe earlier to use with Santyl, P (Plan) Staff to continue Santyl and Vashe dressing. Will follow PRN (Whenever necessary).
On 01/20/15 at 08:00 the nurses' note indicates a coccyx wound is noted. There is no indication what treatment if any was provided to this wound. 20:00 pressure ulcer sacrum
01/21/15 - 08:00 wound sacrum; 12:29 speech therapy; 16:10 Patient refused assistance with CNA (Certified Nursing Assistant) to get back in bed nurse assisted; 20:00 sacrum pressure ulcer
01/22/15 - 08:00 Skin tears to left hand, wound sacrum; 09:30 skin tear to left hand cleansed dressing applied; 10:37 speech therapy MBS completed, decreased laryngeal movements, recommend NPO occasional ice chips; 13:00 scant amount of blood in right nostril; 18:00 emesis small amount of blood, PRN med for N&V given; 20:00 left hand wound, sacrum wound.
The nurses' note on 01/23/15 at 08:00 indicates scattered scars and sacrum wound. There is no documentation where the scars are. 13:42 PICC line discontinued by IV therapy
Patient #10 was discharged on 01/23/15

Patient #10 was readmitted on 01/25/15 via the ED with a diagnosis of SIRS and sacral decubitus (pressure sore).
The review of Patient #10's medical record revealed the following notations:
On 01/25/15 at 16:44 IV placed; 17:55 pressure ulcer stage IV sacrum, healed midline incision to back neck, total care bed, peri wound skin macerated, reposition q2h (every 2 hours) mepilex applied; 17:32 attending physician orders a Enterostomal Therapy Consult/Treatment Expedite once; 20:11 no PICC line, stage IV pressure wound; 19:45 C-collar intact, midline incision, puncture wound anterior abdomen upper left, sacrum pressure ulcer mepilex intact.
Staff Member #16 stated, "Expedite once means less than a STAT order but more than a standard order."
01/26/15 - 02:00 Fentanyl patch removed; 08:00 sacrum wound Aquacell applied wound open to air; 20:00 Sacrum stage II. There is no indication the pressure ulcer had improved to a St
01/27/15 - Stage II sacrum dressing CDI (Clean Dry and Intact); 19:37 C/O nausea, Zofran given 20:00 Stage II dressing CDI; 22:35 Jevity increased, Imodium (first documentation of tube feeding.
01/28/15 -01:15 Condom cath removed, using urinal; 08:00 pressure ulcer sacrum. There is no documentation related to the condition of wound or dressing. 15:15 New tube feeding with TwoCal; 19:43 Sleeping, feeding infusing; 20:00 PEG with dressing clean dry intact, sacrum stage II, dressing clean dry intact.
01/29/15 08:00 pressure ulcer sacrum; 10:17 Enterostomal Therapy Focus Note: Pt seen for reassessment of sacral wound. Pt has a stage IV ulceration that was present on admission. Pt has been using Santyl and wound is starting to show pink tissue scattered to the base of the wound. Wound appears better that prior admission as slough is starting to lift. Answered family's questions and discussed with (Name of attending physician), will add Vashe to the treatment plan with Santyl. Will con't to follow as needed for care; 13:30 speech therapy; 14:03 documented intake of 1060 orally (Patient #10 can't swallow and is NPO); 18:45 feeling nauseated, PRN med given for nausea, tube feeding paused, med for nausea did not help, given med for anxiety, tube feeding restarted, pt fell asleep and when woke up continued to complain of nausea, tube feeding stopped; 19:30 tube feeding off, cont. to complain of nausea; 20:00 Stage II sacrum dressing clean dry and intact. There was no evidence of any dressing changes to sacrum wound.
01/30/15 - 14:00 call to pharmacy to inform them the PICC line had been placed and that Patient #10 was being picked up for transfer to another facility at 16:00. Pharmacy reported the policy is to start TPN (Total Parenteral Nutrition) at 18:00. If it (the TPN) is made now (Name of receiving hospital) would discard it (the TPN). 15:56 call to on call physician at son's request. Son states (Name of Patient #10) has not had anything to eat or drink for 22 hours. On call physician states, "unable to speak with son at this time because he/she is not in or near the hospital. He/She (physician on call) asked (caller) if it was anything specific he/she needed to address and (caller) told him/her the son was concerned because (Name of Patient #10) had not had anything to eat or drink for 22 hours. He/She (physician on call) told caller to let the son know that he/she addressed this concern with him (the son) earlier this morning and that the TPN and his/her (Patient #10) diet would be assessed at (Name of hospital Patient #10 was being transferred to) who would then make the determination as to his diet.
Patient #10 was NPO from 1/15/15 until discharge on 1/30/15.
The Intake and Output records for Patient #10 from 1/25/15 to 1/30/15 documented the following:
1/25/15 20:00 to 23:00 intake 335 ml (milliliters) output 200 ml = +135.00 ml
1/26/15 24:00 to 12:00 intake 1,526 ml output 3,001 ml = -1475 ml
1/27/15 05:32 to 23:44 intake 400 ml output 3,840 ml = -3,440 ml
1/28/15 02:30 to 23:00 intake 100 ml output 1,450 ml = -1,350 ml
1/29/15 01:40 to 22:34 intake 2,020 ml output 1,835 ml = +185 ml this was the only documentation of the amount of tube feeding given
1/30/15 04:30 to 05:09 intake 0 ml output 276 ml (had liquid stool which was documented as 1 ml) = -276 ml
Total documented intake 4,381 ml and output 10,602 ml for this admission leaving a negative balance of 6,221 ml
The facility policy on Tube Feeding, Adult C20.1 was provided on 2/2/15 and documents on page 3 of 4 section 6 "Documentation: Record time and amount of feeding and fluids in the Electronic Health Record. Document the patient's response to tube feeding, presence of abdominal distention, bowel sounds, vomiting, cramps or diarrhea when indicated."
Patient #10 was discharge on 01/30/15 at 16:30 to another facility.

Based on observations, interviews and document review, the facility failed to disinfect medication vials with alcohol prior to piercing the rubber septum and failed to maintain compliance with all their polices, procedure protocols and other infection control program requirements as evidenced by, medical staff entering patient room with stethoscope in pocket and purse on shoulder, long sleeve shirts and exposed undergarments worn under surgical scrubs in Operating Room suites, medical staff wearing surgical mask hanging around neck outside of Operating Room Suites, blood on torn surface of step stool in Labor and Delivery Operating Room, blood on floor tracked from Labor and Delivery Operating Room into hallway and another room across the hallway and glucometer and container with glucometer strips in warmer with newborn not cleaned after use.

The findings include:
1. On 02/04/15 at approximately 1:00 pm the surveyor observed Employee # 20 open a medication vial and withdraw the medication without disinfecting the rubber septum prior to piercing the rubber septum.
On 02/04/15 at approximately 3:00 pm the surveyor observed Employee #21 open a medication vial and withdraw the medication without disinfecting the rubber septum prior to piercing the rubber septum.
On 02/04/15 at 3:30 pm the surveyor conducted an interview with the Chief Nursing Officer. He/she stated the expectation would be to disinfect the vials with alcohol prior to piercing the rubber septum.
On 02/05/15 at 9:56 am the Accreditation Manager gave the surveyor Medication Administration by Mosby ' s Skills. He/she stated that these are the standards used by the facility;
Medication Administration: Injection Preparation from Ampules and Vials.

Preparing a Vial Containing a Solution:

1. Remove the cap covering top of unused vial to expose sterile rubber seal; the cap for a multi-dose vial may have been removed already. Firmly and briskly wipe surface of rubber seal with alcohol swab, and allow it to dry.



34452



2. On February 2, 2015 at approximately 11:45 a.m., Staff Member #26 was observed entering patient #1's room carrying a stethoscope in pocket with purse on shoulder. Patient #1 had been admitted for a surgical site debridement due to infection.

On February 4, 2015 at approximately 1:00 p.m., Staff Member #24 and a Medical Student was observed wearing long sleeves under surgical scrubs and Staff Member #23 and #27 were observed with exposed undergarments under surgical scrubs. The facility's policy titled "RRMC/HSC/Surgical Services Category: Surveillance, Prevention and Control of Infection" states "long sleeved shirts under scrub tops are not permitted. Any undergarments must be covered by scrubs."

On February 4, 2015 at approximately 1:30 p.m., Staff Member #11 was observed placing the glucometer and container with glucometer strips in warmer with infant. The glucometer and container with glucometer strips were not cleaned or discarded after use. An interview with staff member #11 revealed that the glucometer is used on multiple patients and it is to be cleaned after patient use. The facility's policy titled "RRMC Category: Administration Policy, Chapter 400, Surveillance Prevention and Control of Infection" states "Glucometers are to be cleaned after each use".

On February 4, 2015 at approximately 2:00 p.m., blood was observed on a torn step stool in the Labor and Delivery Operating Room. An interview with Staff Member #12 revealed that staff clean the torn step stool as they would clean any other operating room equipment. Staff was unable to provide manufactures guidelines for cleaning the equipment. Staff Member #19 stated that she/he was unaware of the torn step stool. On February 5, 2015 at 11:40 a.m. it was observed that the torn step stool was no longer in the Labor and Delivery Operating Room. The facility's policy titled "Chapter 8 - Special Care Areas" states Damaged or worn equipment should be replaced.

On February 4, 2015 at approximately 2:15 p.m., blood was observed on the floor in the hallway outside of the Labor and Delivery Operating Room into the room across the hall. Interview with Staff Member #11 and #12 reveal that staff members are required to remove shoe covers before exiting the Labor and Delivery Operating Room. Staff Member #11 was observed wearing shoe covers in hallway and in room across the hall. Staff Member #11 then walked back to Labor and Delivery Operating Room and removed shoe covers. The facility's policy titled " RRMC/HSC/Surgical Services Category: Surveillance, Prevention and Control of Infection" states "when leaving the surgical suite, masks and shoe coverings are to be removed and changed upon return".

On February 4, 2015 at approximately 2:30 p.m. and on February 5, 2015 at approximately 2:00 p.m., Staff Member #23 was observed wearing a surgical mask hanging around neck outside of the Operating Rooms. An interview with Staff Member #18 on February 5, 2015 at approximately 2:30 p.m. revealed that staff are required to remove mask and shoe covers when leaving the Operating Room. The facility's policy titled "RRMC/HSC/Surgical Services Category: Surveillance, Prevention and Control of Infection" states "Mask must be secure to prevent venting from the sides and must cover the mouth and nose completely. They should be either on or off and never saved in a pocket for reuse or hanging around neck and should be handled by the strings rather than the body of the mask to avoid contaminations".

Based on interviews, clinical record reviews and select policy and procedures, it was determined that one patient (Patient #6) was not provided with a list of Medicare participating Home Health Agencies (HHA) or Skilled Nursing Facilities (SNF) that provide post hospital services.

The findings include:
In the afternoon of 02/03/15 a review of Patient #6 was reviewed by the surveyor. There was no evidence in the clinical record that the patient and or representative was provided with a list of Medicare participating HHA or SNF that provided post hospital services that could meet the patient's medical needs.
On 2/03/15 an interview was conducted with Staff #5. He/she stated it was their expectation that every patient needing post hospital services be given a Freedom of Choice acknowledgement form. Staff #5 was not able to provide any addition evidence.
On 02/03/15 at 2:15 pm a review of the policy and procedure was reviewed by the surveyor.
Policy and Procedure: Patient Choice
Procedure
· The Riverside Health System (RHS) Care Management (CM) staff will discuss with the patient and/or representative any services identified to be medically necessary by the physician upon discharge and answer any questions and will provide the patient and /or representative with a list of service providers within the patient's geographical area.
· The patient or representative will be asked to choose a provider(s) for any additional healthcare services needed and sign a Freedom of Choice (FOC) acknowledgement form.