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28020


Based on interview and record review, the facility failed to ensure that they had an effective governing body responsible for the quality of care for the patients. The facility failed to ensure that:

1. A physician assessed and documented an assessment of a hospital acquired pressure ulcer to the coccyx (tailbone region) and left heel for 1 of 13 sampled patients (Patient 5) (Refer to A-0049 and A-0347).

2. 1 of 13 sampled patients (Patient 5) who was admitted to the facility free of skin breakdown, did not acquire a pressure ulcer while in the facility and that nursing assessments accurate and documented the full scope of the pressure ulcer. These failures resulted in Patient 5 developing an unstageable pressure ulcer (full thickness tissue loss) to the left heel and an unstageable pressure ulcer to the coccyx region (tail bone and buttocks area).

The facility failed to ensure that a Registered Nurse (RN) supervised and evaluated the care for 1 of 13 sampled patients (Patient 3). The RN failed to perform an initial skin assessment after a Licensed Vocational Nurse (LVN) conducted an initial admission assessment and incorrectly assessed a pressure ulcer on Patient 3's sacrum (tailbone) region. This failure contributed to an incorrect assessment of the Patient 3's condition. (Refer to A-0395)

3. The nursing staff developed and kept a current plan of care that reflected 3 of 13 sampled patients (Patient 3, 5 and 1), needs and interventions regarding pressure ulcers. For Patient 3, the plan of care was not revised to reflect a pressure ulcer on the sacrum (tailbone) region. For Patient 5, the plan of care did not reflect a pressure ulcer on the coccyx (tailbone region) and both heels. The facility failed to ensure that Patient 5's plan of care reflected the physicians plan for Patient 5's care needs. For Patient 1 the plan of care did not have measureable goals or an evaluation of the care plan's effectiveness. These failures contributed to the patients not having the optimal care to meet their highest level of well being. (Refer to A-396)

4. A Registered Nurse who was covering for a Wound Care Nurse and conducting wound assessments of patients, was adequately trained and competent to care for patients who required "Wound Care Evaluations." This failure resulted in 1 of 13 sampled patients (Patient 5) to not receive the necessary care and services from a Wound Care Nurse, which was ordered by the physician. (Refer to A-0397)

5. A nursing standardized procedure was developed to administer antipyretics (medication to treat increased body temperature), Tylenol (acetaminophen) and Motrin (ibuprofen) to patients of all ages seen in the emergency department (ED). That this standarized procedure was consistent with the requirements for supervision and education as stipulated in the statute and that the content of the policy matched the actual practice that occurred in the ED. (Refer to A-500)

6. Adequate oversight was provided to the dietary service department as evidenced by observations of deficient practices related to 1) safe food handling and 2) a failure to ensure patients' therapeutic diets were consistent with the physician ordered diets. Failure to ensure adequate oversight of department activities by the director of food services resulted in unsafe food handling that put the patients at risk for food borne illness. It also resulted in the potential for not meeting the nutrition needs of the patients and for further compromise to their medical status. (Refer to A-0620)

7. The diets served to 2 of 3 patients reviewed for nutrition care were consistent with the physician ordered diets (Patients 9 and 10). For Patient 9, the physician ordered "Diet as Tolerated, ADA restrictions (diabetic)" and the diet served was an "1800 calorie ADA" diet. For Patient 10 the physician ordered a Regular diet and the patient was served a Renal diet (for patients with impaired kidney function). This failure to ensure that patients received the physician ordered diets had the potential for the nutrition needs of the patient to not be met and further compromise their medical status. (Refer to A-0629)

8. There were infection control measures in place to prevent the development of food borne illness and cross contamination in the food service departments. The hospital failed to have a thorough infection control surveillance system that monitored the conditions and practices of the dietetics services staff. By not having these measures and a thorough surveillance system, potentially hazardous foods stored, prepared and distributed under unsafe and unsanitary conditions and there was potential for such continuation in the absence of identification and remediation. (Refer to A-0749)

The cumulative effect of this systemic problem, resulted in the facility's inability to provide quality health care in a safe environment.

28020



Based on interview and record review, the facility failed to ensure that a physician assessed and documented a hospital acquired pressure ulcer of the coccyx and left heel for 1 of 13 sampled patients (Patient 5).

Findings:

According to the "National Pressure Ulcer Advisory Panel's-Pressure Ulcer Staging Classification Definitions of Pressure Ulcers" and the classification system that the facility used as guidance on their form titled, "Photographic Wound Documentation, PHSI-100-035 (01/12),"
A deep tissue injury was characterized by a purplish or maroon discolored intact area or blood-filled blister due to underlying soft tissue injury.

A Stage 1 was non-blanchable (skin redness that persists when pressure is applied to the reddened area) with persistent redness that did not quickly fade and the skin was intact.

A Stage 2 was a partial thickness (tissue loss) which presented as a shallow open ulcer with a red-pink wound bed and without slough (black or tan overlay).

A Stage 3 was full thickness tissue loss and subcutaneous fat may have been visible but bones, tendon and muscle were not exposed.

A Stage 4 was full thickness tissue loss with extensive tissue exposure and destruction to muscle, bone or supporting tissues.

An unstageable pressure ulcer was full thickness tissue loss which was covered by a black or tan overlay in the wound area and was unable to be staged until the overlay was removed.

A record review on 5/17/12, at 9:15 AM, of Patient 5, indicated that the patient was admitted on 4/27/12, with a diagnosis of a hip fracture. Patient 5 had surgery on 4/30/12, to repair the fracture.

An interview and a concurrent record review was conducted on 5/17/12, at 9:35 AM, with a Medical Surgical/Telemetry Charge Nurse. He stated that according to Patient 5's initial nursing skin assessment, on 4/27/12, Patient 5's skin was normal and had no pressure ulcers. He also stated that on 4/30/12, a surgical nurse documented, prior to Patient 5's surgery, that the patient had no pressure ulcers and the skin was dry, intact and normal. Additionally, when Patient 5 was transferred from surgery to the Intensive Care Unit (ICU), on 4/30/12, the ICU nurse documented that Patient 5's skin was normal. No pressure ulcers were documented.

A record review and a concurrent interview, on 5/17/12, at 10 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse. The Charge Nurse stated that according to the "Wound Assessment/Photographic Wound Documentation" form, a registered nurse (RN), documented that on 5/1/12, at 4 PM, Patient 5 had a "Brownish discoloration and redness" to the sacrum area (tailbone) that measured 5 x 3 centimeters. In the section, titled "Physician assessment," the physician documented that the pressure ulcer was present on admission. The Charge Nurse stated that according to 3 previous skin assessments conducted on Patient 5's skin, when the patient was admitted, Patient 5 had no pressure ulcers on admission. Additionally, the physician indicated that the pressure ulcer was a stage 1. There was no documented evidence that the physician measured the pressure ulcer, there was no documented evidence of a physician description and location of the pressure ulcer and there was no documented evidence that the physician conducted his own assessment of the pressure ulcer. The Charge Nurse stated, that it was unclear when the physician looked at the photograph of the wound because the date was not legible and there was no documented evidence whether the physician examined Patient 5's pressure ulcer or if he examined the photograph that nursing took of the pressure ulcer.

A record review and a concurrent interview, on 5/17/12, at 10:40 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse, of Patient 5's wound assessment dated 5/5/12. The photograph was of Patient 5's coccyx region, which appeared dark purple with an area that was dark brown/black and the area around the pressure ulcer was red. There were no measurements or descriptions of the pressure ulcer and it was not staged. The "Physician Assessment" section contained a physician's signature, however it did not contain the physician's assessment of Patient 5's pressure ulcer and it was not dated or timed. Additionally, there was no documented evidence in the medical record that Patient 5's physician performed an assessment or looked at the pressure ulcer. The Charge Nurse stated that he was unable to find a physician assessment of Patient 5's pressure ulcer.

A record review and a concurrent interview, on 5/17/12, at 10:40 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse, of Patient 5's wound assessment and photograph dated 5/6/12, at 5:13 AM. An RN documented that Patient 5 had a wound on the coccyx region. The staging of the wound was not documented and there were no measurements documented. The photograph showed an open area however the majority of the area that surrounded the open sore was covered with a dark blackish/brown overlay and had redness around the dark area. The picture, showed an unstageable pressure ulcer, according to the Charge Nurse. A second picture was also taken of Patient 5's left heel. The RN documented that it was an "Unstageable Pressure Ulcer." The "Physician Assessment" section contained a physician signature however it had no date or time and no physician assessment of the pressure ulcers. The physician documented that the pressure ulcer on the coccyx was not present on admission and that it was a "skin tear." The Charge Nurse stated that he was unable to find a physician assessment of the pressure ulcers.

A record review and a concurrent interview, on 5/17/12, at 10:55 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse, of Patient 5's "Wound Assessment/Photographic Wound Documentation," dated 5/13/12, at 3 PM. An RN who was covering for a Wound Care Nurse, conducted the assessment and documented that Patient 5 had a wound to the sacrum area. There was no staging of the pressure ulcer documented. The picture showed a large pressure ulcer that was open and had dark discoloration around the open area. The "Physician Assessment" section, contained a physician's signature however the Charge Nurse could not read the date or time and the physician's assessment was left blank. The Charge Nurse stated that he could not find a physician assessment of the pressure ulcer.

A record review and a concurrent interview, on 5/17/12, at 10:55 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse, of Patient 5's "Wound Assessment/Photographic Wound Documentation," dated 5/13/12, at 10 PM of the left heel. The RN did not stage the pressure ulcer. The picture showed a large dark purple and red pressure ulcer that covered the entire area of the heel. The "Physician Assessment" section, contained a physician's signature however the Charge Nurse could not read the date or time and the physician's assessment was left blank. The Charge Nurse stated that he was unable to find a physician assessment of the pressure ulcer.

A record review, on 5/17/12, at 3 PM, of the facility's "Medical Staff Rules and Regulations," documented the following: "...All practitioners understand and accept the principle that Hospital Medical staff privileges are dependent upon individual skill and training and not solely on licensure. The primary responsibility of a practitioner is to render medical care to the sick and injured persons who have selected him or her as their practitioner, or who have been placed in his or her care by a responsible agent. In discharging this responsibility he or she brings to bear all his or her medical skill and judgment ..."

Based on interview and record review the facility failed to ensure that 1 of 13 sampled patients (Patient 6) had the right to make an informed decision regarding an invasive diagnostic procedure. This failure had the potential for the patient to have a procedure without understanding the risks and benefits of the procedure.

Findings:

A review on 5/16/12 of the medical record for Patient 6 showed a consent form for a liver biopsy under computerized tomography guidance. There was a section on the form for the physician to indicate that the patient received information regarding the risks and benefits of the procedure, the risk of not performing the procedure, any adverse reactions that may reasonably be expected to occur or any alternative methods of treatment. There was no physician signature, or date and time to indicate that the patient received the information needed to make an informed decision.

There was no documentation in the progress notes by the physician indicating that a informed consent had been obtained.

Patient 6 underwent the procedure on 5/9/12.

In an interview on 5/16/12 at 10:00 AM with the Director of the Medical-Surgical unit, the Director acknowledged that the informed consent should have been done. The Director stated that " At least should have been documented in the progress notes. "

A review of the Medical Staff Rules and Regulations dated 5/12 showed the following:

" No procedures, surgical or otherwise, are to be performed unless the patient or the patient ' s authorized representative has given written informed consent as required by the applicable laws and regulations. It is the treating physician ' s responsibility to obtain and document, in the patient ' s record, the informed consent. "

Based on interview and record review, the facility failed to ensure that a physician assessed and documented an assessment of a hospital acquired pressure ulcer to the coccyx and left heel for 1 of 13 sampled patients (Patient 5).

Findings:

According to the "National Pressure Ulcer Advisory Panel's-Pressure Ulcer Staging Classification Definitions of Pressure Ulcers" and the classification system that the facility used as guidance on their form titled, "Photographic Wound Documentation, PHSI-100-035 (01/12),"
A deep tissue injury was characterized by a purplish or maroon discolored intact area or blood-filled blister due to underlying soft tissue injury.

A Stage 1 was non-blanchable with persistent redness that did not quickly fade and the skin was intact.

A Stage 2 was a partial thickness (tissue loss) which presented as a shallow open ulcer with a red pink wound bed and without slough (black or tan overlay).

A Stage 3 was full thickness tissue loss and subcutaneous fat may have been visible but bones, tendon and muscle were not exposed.

A Stage 4 was full thickness tissue loss with extensive tissue exposure and destruction to muscle, bone or supporting tissues.

An unstageable pressure ulcer was full thickness tissue loss which was covered by a black or tan overlay in the wound area and was unable to be staged until the overlay was removed.

A record review on 5/17/12, at 9:15 AM, of Patient 5, indicated that the patient was admitted on 4/27/12, with a diagnosis of a hip fracture. Patient 5 had surgery on 4/30/12, to repair the fracture.

An interview and a concurrent record review was conducted on 5/17/12, at 9:35 AM, with a Medical Surgical/Telemetry Charge Nurse. He stated that according to Patient 5's initial nursing skin assessment, on 4/27/12, Patient 5's skin was normal and had no pressure ulcers. He also stated that on 4/30/12, a surgical nurse documented, prior to Patient 5's surgery, that the patient had no pressure ulcers and the skin was dry, intact and normal. Additionally, when Patient 5 was transferred from surgery to the Intensive Care Unit (ICU), on 4/30/12, the ICU nurse documented that Patient 5's skin was normal. No pressure ulcers were documented.

A record review and a concurrent interview, on 5/17/12, at 10 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse. The Charge Nurse stated that according to the "Wound Assessment/Photographic Wound Documentation" form, a registered nurse (RN), documented that on 5/1/12, at 4 PM, Patient 5 had a "Brownish discoloration and redness" to the sacrum area (tailbone) that measured 5 x 3 centimeters. In the section, titled "Physician assessment," the physician documented that the pressure ulcer was present on admission. The Charge Nurse stated that according to 3 previous skin assessments conducted on Patient 5's skin, when the patient was admitted, indicated that Patient 5 had no pressure ulcers on admission. The physician indicated that the pressure ulcer was a stage 1. There was no documented evidence that the physician measured the pressure ulcer, there was no documented evidence of a physician description and location of the pressure ulcer and there was no documented evidence that the physician conducted his own assessment of the pressure ulcer. The Charge Nurse stated, that it was unclear when the physician looked at the photograph of the wound because the date was not legible and there was no documented evidence that the physician physically looked at Patient 5's pressure ulcer or if he just looked at the photograph that nursing took of the pressure ulcer.

A record review and a concurrent interview, on 5/17/12, at 10:40 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse, of Patient 5's wound assessment dated 5/5/12. The photograph was of Patient 5's coccyx region, which appeared dark purple with an area that was dark brown/black and the area around the pressure ulcer was red. There were no measurements or descriptions of the pressure ulcer and was not staged. The "Physician Assessment" section contained a physician's signature, however it did not contain the physician's assessment of Patient 5's pressure ulcer and it was not dated or timed. Additionally, there was no documented evidence in the medical record that Patient 5's physician performed an assessment or looked at the pressure ulcer. The Charge Nurse stated that he was unable to find a physician assessment of Patient 5's pressure ulcer.

A record review and a concurrent interview, on 5/17/12, at 10:40 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse, of Patient 5's wound assessment and photograph dated 5/6/12, at 5:13 AM. An RN documented that Patient 5 had a wound on the coccyx region. The staging of the wound was not documented and there were no measurements documented. The photograph showed an open area however the majority of the area that surrounded the open sore was covered with a dark blackish/brown overlay and had redness around the dark area. The picture, showed an unstageable pressure ulcer, according to the Charge Nurse. A second picture was also taken of Patient 5's left heel. The RN documented that it was an "Unstageable Pressure Ulcer." The "Physician Assessment" section contained a physician signature however it had no date or time and no physician assessment of the pressure ulcers. The physician documented that the pressure ulcer on the coccyx was not present on admission and that it was a "skin tear." The Charge Nurse stated that he was unable to find a physician assessment of the pressure ulcers.

A record review and a concurrent interview, on 5/17/12, at 10:55 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse, of Patient 5's "Wound Assessment/Photographic Wound Documentation," dated 5/13/12, at 3 PM. An RN who was covering for a Wound Care Nurse, conducted the assessment and documented that Patient 5 had a wound to the sacrum area. There was no staging of the pressure ulcer documented. The picture showed a large pressure ulcer that was open and had dark discoloration around the open area. The "Physician Assessment" section, contained a physician's signature however the Charge Nurse could not read the date or time and the physician's assessment was left blank. The Charge Nurse stated that he could not find a physician assessment of the pressure ulcer.

A record review and a concurrent interview, on 5/17/12, at 10:55 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse, of Patient 5's "Wound Assessment/Photographic Wound Documentation," dated 5/13/12, at 10 PM of the left heel. The RN did not stage the pressure ulcer. The picture showed a large dark purple and red pressure ulcer that covered the entire area of the heel. The "Physician Assessment" section, contained a physician's signature however the Charge Nurse could not read the date or time and the physician's assessment was left blank. The Charge Nurse stated that he was unable to find a physician assessment of the pressure ulcer.

A record review, on 5/17/12, at 3 PM, of the facility's "Medical Staff Rules and Regulations," documented the following: "...All practitioners understand and accept the principle that Hospital Medical staff privileges are dependent upon individual skill and training and not solely on licensure. The primary responsibility of a practitioner is to render medical care to the sick and injured persons who have selected him or her as their practitioner, or who have been placed in his or her care by a responsible agent. In discharging this responsibility he or she brings to bear all his or her medical skill and judgment ..."

28020


Based on interview, and record review the facility failed to have a well organized nursing service to provide 24-hour nursing services to all patients by failing to:

1. Ensure that 1 of 13 sampled patients (Patient 5), did not develop hospital acquired pressure ulcers (Refer to A-395).

2. Ensure that RNs accurately assessed and documented the full scope of Patient 5's hospital acquired pressure ulcers (Refer to A-395).

3. Ensure that an RN supervised and evaluated the nursing care for each patient as directed by scope of practice and facility policy (Refer to A 395).

4. Ensure that a LVN (Licensed Vocational Nurse) did not perform an initial and incorrect skin assessement on 1 of 13 sampled patients (Patient 3) sacrum pressure ulcer (Refer to A-395).

5. Ensure that the nursing staff developed and kept current a nursing care plan for each patient (Refer to A 396).

6. Ensure that nursing staff was assigned to the care of each patient in accordance with the specialized qualification and competences of the nursing staff by failing to ensure that assignments were made according to patient need (Refer to A 397).

The cumulative effect of these systemic problems resulted in the facility's failure to deliver patient care in a safe manner and in compliance with the Condition of Participation for Nursing Services.

26500

Based on interview and record review, the facility failed to provide nursing services that was supervised and evaluated by a Registered Nurse (RN) when:

1. The facility failed to follow its nursing policy and procedure (P&P) titled, "Skin Integrity" when a Registered Nurse (RN) failed to supervise and evaluate the nursing care for 1 of 13 sampled patients (Patient 4), who was admitted to the facility with a right heel pressure ulcer (PU- a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The nursing staff failed to ensure that the patient's right heel PU was assessed every shift according the the facility's P&P. The nursing staff also failed to ensure that the patient received care and services for the right heel wound infection that was identified by positive wound cultures. The nursing staff further failed to ensure that the surgical wound consult was conducted timely.

2. The facility failed to ensure that 1 of 13 sampled patients, (Patient 5) admitted to the facility, free of skin breakdown, did not acquire a pressure ulcer while in the facility and that nursing assessments accurately assessed and documented the full scope of the pressure ulcer. These failures resulted in Patient 5 developing an unstageable pressure ulcer (full thickness tissue loss) to the left heel and an unstageable pressure ulcer to the coccyx region (tail bone and buttocks area).

3. The facility failed to ensure that a Registered Nurse (RN), supervised and evaluated the care for 1 of 13 sampled patients (Patient 3) and performed an initial skin assessment after a Licensed Vocational Nurse (LVN) conducted an initial admission assessment and incorrectly assessed a pressure ulcer on Patient 3's sacrum (tailbone) region. This failure contributed to an incorrect assessment of the Patient 3's condition.

These failures had the potential to contribute in the increased risk of harm to the universe of 40 patients due to nursing care that was provided by the facility that was not being supervised and evaluated by an RN.

Findings:

1. According to the National Pressure Ulcer Advisory Panel (NPUAP), dated February 2007, a Pressure Ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.

Pressure Ulcer Stages (staging a system developed to guide the clinical description of the depth of tissue destruction that occurs with pressure ulcers) include:

Stage III- consists of full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss.

Unstageable- consists of full thickness tissue loss in which the base of the ulcer is covered by slough (non viable tissue that is yellow, tan, gray, green or brown) and/or eschar (non viable tissue that is tan, brown or black) in the wound bed.

A review of the facility's policy and procedure titled, "Skin Integrity," that was approved by the Governing Body in 5/12, was conducted and noted the following:

Purpose: To provide guidelines for assessment of skin integrity, to determine risk of developing pressure ulcers, to develop a plan of care for prevention of pressure ulcers in those patients determined to be at risk and to provide guidelines for treatment.

The Assessment and Monitoring of Wounds: Staging of pressure ulcers should be deferred to wound care nurses, allied healthcare professionals, and physicians.

Pressure Ulcer Classifications System (International NPUAP-EPUAP 2009, Guidelines:

Category/Stage III- full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. "Slough may be present but does not obscure the depth of tissue loss."

Unstageable/Unclassified: full thickness tissue loss in which actual depth of the ulcer is "completely" obscured by slough and/or eschar in the wound bed. "Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined."

A). Skin Integrity- The patient's skin integrity from head to toe will be assessed upon admission by the Registered Nurse (RN). Each consecutive shift, the data collection may be performed by either Registered Nurse (RN) or Licensed Vocational Nurse (LVN).

C). Wound Assessment- the RN or LVN will document their assessment of each wound by including the following in their documentation but should not be limited to the following:

1. Location - (wound or ulcer location on body)
2. Size - (length X width X depth in centimeters [cm])
3. Wound/Periwound Skin Color (describe the wound bed/periwound appearance [pink or beefy red; black, gray or dark brown (eschar); yellow to while (slough)
4. Drainage- amount: small, medium or heavy; color/consistency; odor (present or not)
5. Undermining (tissue destruction to underlying intact skin along wound margins)/Tunneling
6. Pain- associated with the wound
7. Infection- symptoms present or not, describe signs and symptoms

D). Photographing- wounds should be photographed, upon admission, and upon discharge from the hospital. Wound photographs should also be obtained upon discovery of new wounds and changes in condition of the wound.

On 5/15/12, a review of Patient 4's electronic medical record was conducted with the Director of Medical Surgical/Telemetry Units (DMSTU).

A review of the face sheet showed that the patient was admitted to the Medical/Surgical Telemetry Unit (MSTU) on 4/30/12, from the emergency department (ED) with diagnoses that included pneumonia (bacterial lung infection). Patient 4 was discharged from the facility on 5/7/12.

A review of the "Wound Assessment and Photographic Wound Documentation," dated 4/30/12 at 9 PM, was conducted and revealed that the patient had a Stage III right heel PU that measured 3 cm x 3 cm x 1 cm. The wound bed color was red, pink and yellow, and the periwound (surrounding tissue) was red. The PU had a foul odor, and the patient had pain to the site. The photographic section of the document revealed a photograph of a right heel pressure ulcer that consisted of full thickness tissue loss in which the base of the ulcer was covered by slough (Unstageable).

A review of the "Wound Assessment and Photographic Wound Documentation," dated 4/30/12 at 10 PM, was conducted and revealed the the patient had a Stage III right heel PU that measured 5 cm x 4 cm x 0.2 cm. The wound bed color was yellow, and the periwound was red. The PU had a mild odor. A review of the photographic section of the document revealed a photograph of a pressure ulcer that consisted of full thickness tissue loss in which the base of the ulcer was covered by slough (Unstageable).

A review of the Wound/Skin Care Physician Orders (PO), dated 4/30/12, included, a surgical wound consult, and a wound consult (conducted by the Wound Care Nurse).

A review of the Daily Nursing Wound Assessments, dated 5/1/12, was conducted and revealed that the nursing staff failed to evaluate the the patient's PU according to the Skin Integrity P&P as follows:

a.) 5/1/12 at 5:27 AM- no assessment of the wound bed was noted.
b). 5/1/12 at 8 PM- no assessment of the wound bed was noted.

A review of the physician order (PO), dated 5/2/12 at 7 AM, revealed an order for a "wound culture."

A review of the laboratory results for the wound culture, dated 5/5/12, revealed that the patient's right heel wound was positive for three bacterial microorganisms (Morganella morganii is a species of Gram-negative bacillus bacteria; Proteus mirabilis is a Gram-negative; Staphylococcus aureus [wound infection]). The medical record failed to show that the patient's right heel positive wound cultures, dated 5/5/12, were followed-up on to ensure timely treatment was administered.

A review of the Daily Nursing Wound Assessments, dated 5/2/12 at 8 AM, was conducted and revealed that the nursing staff failed to evaluate the the patient's PU according to the Skin Integrity Policy and Procedure (P&P) as follows, the PU was not measured, nor was an evaluation of the wound bed noted.

A review of the Wound Care Nurse's (WCN), "Wound Consultation," dated 5/2/12, was conducted and revealed the wound assessment as the patient having had a right heel Stage III PU that measured approximately 5 cm x 4 cm x 0.3 cm. The wound bed had 75% yellow slough and 25 % pink tissue (Unstageable due to the base of the wound being covered by slough). The wound bed was dry with a foul odor, and periwound was calloused and dry.

A review of the PO, dated 5/2/12 at 11 AM, revealed an order for a "surgical consult."

There was no documented evidence to show that the surgical wound consult was done as ordered.

A review of the Daily Nursing Wound Assessments, dated 5/2/12 at 8 AM through 5/6/12, was conducted and revealed that the nursing staff failed to evaluate the the patient's PU according to the Skin Integrity P&P as follows:

a). 5/2/12 at 8 PM- The PU was not measured, nor was an assessment of the wound bed noted.

b). 5/3/12 at 8 AM- The PU was not measured, nor was an assessment of the wound bed noted.

c.) 5/3/12 at 8 PM- There were no wound measurements that were noted.

d). 5/4/12 at 8 AM- There were no wound measurements that were noted.

e). 5/4/12 at 7 PM- The PU was not measured, nor was an assessment of the wound bed noted.

f). 5/5/12 at 8 AM- There were no wound measurements that were noted

g). 5/5/12 at 8 PM- The PU was not measured, nor was an assessment of the wound bed noted.

h). 5/6/12 at 12 PM- The PU was not measured, nor was an assessment of the wound bed noted.

i). 5/6/12 at 12:16 PM- The PU was assessed as having had minimal green drainage with muscle visible. According tho the facility's P&P, "Wound photographs should also be obtained upon discovery of new wounds and changes in condition of the wound. "

j). 5/6/12 at 8 PM- The PU was not measured, nor was an assessment of the wound bed noted.

A review of the "Wound Assessment and Photographic Wound Documentation," dated 5/6/12 at 12 PM, was conducted and revealed that the patient had a Stage III right heel PU that measured 5 cm x 5 cm x 1 cm. The wound (bed) color was pink, green and yellow, and the periwound was pink. The PU had a small amount of drainage. The section reserved for the "Stage" of the PU was blank. The photographic documentation revealed a right heel pressure ulcer that consisted of full thickness tissue loss in which the base of the ulcer was covered by slough (Unstageable).

A review of the Daily Nursing Wound Assessment, dated 5/7/12 (day of discharge) at 8 AM, was conducted and revealed that there was no assessment of the wound bed.

The medical record failed to show that the patient's right heel pressure ulcer was photographed upon discharge as required per the facility's P&P.

A review of the medical record failed to show that the surgical wound consult was conducted prior to the patient's discharge on 5/7/12.

On 5/16/12 at 3 PM, an interview was conducted with the Interim Wound Care Nurse (IWCN). She reviewed Patient 4's "Wound Assessment" documentation, dated 4/30/12 and 5/6/12. The IWCN stated that the patient's right heel PU should have been assessed as Unstageable due to the presence of slough obscuring the wound bed.

On 5/16/12 at 3:30 PM, an interview, review of the Skin Integrity P&P, and review of Patient 4's medical record was conducted with the Director of Medical Surgical/Telemetry Units (DMSTU), she confirmed that the facility's P&P noted that the wound base had to be "completely" covered for the wound to be Unstageable; however, she confirmed that the facility's P&P also noted that a Stage III "may have slough present, but it should not obscure the base of the wound."

She confirmed that the "entire" base of the patient's right heel PU could not be visualized due to the presence of slough (Unstageable). The DMSTU acknowledged and confirmed that the facility's Skin Integrity P&P for staging was not followed. She was not knowledgeable regarding the National Pressure Ulcer Advisory Panels (NPUAP) pressure ulcer stages.

During the interview, the DMSTU confirmed that the nursing staff did not evaluate the patient's right heel PU as the facility's Skin Integrity P&P indicated. She stated that the PU should have been evaluated according to the facility's P&P. She also confirmed that a photograph of the patient's right heel wound was not taken upon discharge. The DMSTU stated that the nursing staff should have taken a photograph of the patient's PU upon discharge.

During the interview, the DMSTU confirmed that the patient did not receive medical interventions for the positive right heel wound culture. She stated that there should have been documentation in the medical record to show why the patient's wound infection was not addressed by the facility.

The DMSTU confirmed that the surgical wound consult was not done. She stated that there should have been documentation in the medical record to show why the surgical consult was not conducted as ordered.



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26881




28020



2. According to the "National Pressure Ulcer Advisory Panel's-Pressure Ulcer Staging Classification Definitions of Pressure Ulcers" and the classification system that the facility used as guidance, on their form titled, "Photographic Wound Documentation, PHSI-100-035 (01/12),"

A deep tissue injury was a purplish or maroon discolored intact area or blood-filled blister due to underlying soft tissue injury.

A Stage 1 was non-blanchable with persistent redness that did not quickly fade and the skin was intact.

A Stage 2 was a partial thickness tissue loss which presented as a shallow open ulcer with a red pink wound bed and without slough (black or tan overlay).

A Stage 3 was full thickness tissue loss and subcutaneous fat may have been visible but bones, tendon and muscle were not exposed.

A Stage 4 was full thickness tissue loss with extensive tissue exposure and destruction to muscle, bone or supporting tissues.

An unstageable pressure ulcer was full thickness tissue loss which was covered by a black or tan overlay in the wound area and was unable to stage until the overlay was removed.

A record review on 5/17/12, at 9:15 AM, of Patient 5, indicated that the patient was admitted on 4/27/12, with a diagnosis of a hip fracture. Patient 5 had surgery on 4/30/12, to repair the fracture.

An interview and a concurrent record review was conducted on 5/17/12, at 9:35 AM, with a Medical Surgical/Telemetry Charge Nurse. He stated that according to Patient 5's initial nursing skin assessment, on 4/27/12, Patient 5's skin was normal and had no pressure ulcers. He also stated that on 4/30/12, a surgical nurse documented, prior to Patient 5's surgery, that the patient had no pressure ulcers and the skin was dry, intact and normal. Additionally, when Patient 5 was transferred from surgery to the Intensive Care Unit (ICU), on 4/30/12, the ICU nurse documented that Patient 5's skin was normal. No pressure ulcers were documented.

A record review and a concurrent interview, on 5/17/12, at 10 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse. The Charge Nurse stated that according to the "Wound Assessment/Photographic Wound Documentation" form, a registered nurse (RN), documented that on 5/1/12, at 4 PM, Patient 5 had a "Brownish discoloration and redness" to the sacrum area (tailbone). There was no staging of the pressure ulcer documented by the RN. The Charge Nurse stated that RNs were not supposed to stage pressure ulcers according to facility practice. However, he stated that based on the photograph that the RN took, it appeared that the wound on the coccyx was a Deep Tissue Injury Pressure Ulcer. There was no documented evidence to indicate that the RN notified the physician of the pressure ulcer on 5/1/12, after it was identified.

A record review and a concurrent interview, on 5/17/12, at 10 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse. The Charge Nurse stated that based on the documentation of Patient 5's "Wound/Skin Care Physician Orders," the physician ordered a "Wound Care Evaluation" on 5/1/12, at 4:10 PM. According to the documentation in Patient 5's medical record, the "Wound Care Evaluation" was not done until 5/3/12, at 2:30 PM. Additionally, the Wound Care Nurse who conducted the evaluation, documented the following, "...Present on admission buttocks approximately 5 x 3 centimeters area redness nonblanchable..." However, 3 skin assessments conducted on Patient 5's skin, when the patient was admitted, indicated that Patient 5 had no pressure ulcers on admission. The Wound Care Nurse did not take pictures of the coccyx area when she conducted her assessment of Patient 5 on 5/3/12.

A record review and a concurrent interview, on 5/17/12, at 10:20 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse. The record review, indicated inconsistencies in the RNs' assessments of Patient 5's pressure ulcer, from 5/1/12, the day that an RN identified a pressure ulcer on Patient 5's coccyx, to 5/5/12. Various RNs on both the day shift and the night shift documented that Patient 5 had redness to the coccyx, while others documented maceration (injury accompanied by soft, white deteriorating skin around the site of the pressure ulcer) to the coccyx. Additionally, some RNs documented that Patient 5 had a skin tear to the coccyx and others documented that Patient 5 had a pressure ulcer however no staging of the pressure ulcer was documented. The Charge Nurse agreed with the findings and stated that the documentation of Patient 5's pressure ulcer assessments were inconsistent.

A record review and a concurrent interview, on 5/17/12, at 10:40 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse, of Patient 5's wound assessment dated 5/5/12. The photograph was of Patient 5's coccyx region, which appeared dark purple with an area that was dark brown/black. The RN did not document the measurement and the description of the wound was incomplete. The Charge Nurse agreed with the findings and stated that the nurse should have documented the measurement and a thorough description of the wound. The pressure ulcer was not staged.

A record review and a concurrent interview, on 5/17/12, at 10:40 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse, of Patient 5's wound assessment dated 5/6/12, at 5:13 AM. The RN documented that Patient 5 had a wound on the coccyx region however she did not document the stage of the wound and there were no measurements documented. The RN documented that the wound was pink and brownish. The photograph showed an open area however the majority of the area that surrounded the open sore was covered with a dark blackish/brown overlay and had redness around the dark area. The picture, showed an unstageable pressure ulcer, according to the Charge Nurse and two Department Surveyors. Two additional pictures were also taken of Patient 5's left heel which the RN documented as an "Unstageable Pressure Ulcer" and a picture of the right heel, that the RN documented as "Redness." A "Wound Care Evaluation" was ordered however, there was no documented evidence that the wound evaluation was done. There was no indication that on 5/6/12, the physician was notified of the pressure ulcers.

A record review and a concurrent interview, on 5/17/12, at 10:55 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse, of Patient 5's "Wound Assessment/Photographic Wound Documentation," dated 5/13/12, at 3 PM. The RN who was covering for a Wound Care Nurse, conducted the assessment and documented that Patient 5 had a wound to the sacrum area. There was no staging of the pressure ulcer documented. The Charge Nurse stated that it was because the RN was only a floor nurse, not a Wound Care Nurse and she was not allowed to stage the pressure ulcer. The Charge Nurse also indicated that there was no documented evidence in Patient 5's medical record that a wound evaluation was done by a Wound Care Nurse, after it had been ordered on 5/6/12.

A record review and a concurrent interview, on 5/17/12, at 10:55 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse, of Patient 5's "Wound Assessment/Photographic Wound Documentation," dated 5/13/12, at 10 PM of the left heel. The RN did not stage the pressure ulcer, after it had previously been identified on 5/6/12 by another RN to be an unstageable pressure ulcer. There was no documented evidence that the nurse informed the physician.

An interview was conducted after a record review of Patient 5's nursing assessments, notes and treatments that were provided for Patient 5's pressure ulcers to the coccyx and to the left heel, with a Medical Surgical/Telemetry Charge Nurse, on 5/17/12, at 11:10 AM. He indicated that from 5/1/12, the day that a RN identified a pressure ulcer on Patient 5, to 5/16/12, RN assessments were inconsistently documented. Some RNs failed to document measurements of the pressure ulcers and some RNs failed to provide a description of the pressure ulcer on the coccyx and the left heel.

A record review, on 5/18/12, at 10 AM, of a facility policy titled, "Skin Integrity, revised on February, 2011," was conducted. The policy indicated the following: "...All open pressure ulcers as well as high risk patients...require a wound care consultation referral. ..The RN or LVN will document their assessment of each wound by including the following in their documentation but should not be limited to the following: Location...Size...Wound/Periwound skin color...Drainage...Undermining/Tunneling...Pain...Infection..."

3. A record review, on 5/15/12, at 11 AM, indicated that Patient 3 was admitted to the telemetry floor (a unit that provides cardiac monitoring), on 5/14/12, with a diagnosis of congestive heart failure (heart disease).

A record review, on 5/15/12, at 11 AM, of Patient 3's initial "Wound Assessment and Photographic Wound Documentation," dated 5/14/12, at 4:30 PM, indicated that a LVN (Licensed Vocational Nurse) performed the initial skin assessment of Patient 3. The picture showed a large red pressure ulcer around Patient 3's coccyx area and a small open sore (Stage 2). There was no staging of the pressure ulcer documented and the LVN documented that it was "Pink" but did not mention that the pressure ulcer had an open area.

An interview and a concurrent record review of Patient 3, on 5/15/12, at 11:05 AM, with an Intensive Care Unit (ICU) RN, was conducted. The ICU RN stated that Patient 3 was transferred to ICU in the morning. The ICU RN, performed her own skin assessment and stated that the LVN on telemetry documented that the patient had redness on the sacrum (Stage 1), however the ICU RN stated that Patient 3 had "partial thickness" (open area). She also stated that although she is unable to stage the pressure ulcer, it appeared to be a Stage 2. The ICU RN stated that a RN should have co-signed the LVN's assessment.

An interview, on 5/15/12, at 12 PM, with the ICU/Emergency Department (ED) Director, was conducted. He stated that the LVN was not supposed to perform the initial assessment, it should have been the RN.

An interview, on 5/15/12, at 12:15 PM, with the Director of Medical/Surgical/Telemetry Units, was conducted. After reviewing Patient 3's skin assessment that the LVN performed on Patient 3, on 5/14/12, at 4:30 PM, she stated that LVNs were not supposed to conduct initial assessments. She stated that the LVN could have taken the picture however the RN should have signed the assessment form.

An interview, on 5/15/12, at 12 PM, with the Medical Surgical RN, (RN 3), who was the admission nurse, on 5/14/12. RN 3 stated that she looked at the photograph of Patient 3's pressure ulcer that the LVN took but she did not perform her own assessment. Additionally, she stated that she only looked at "part" of the pressure ulcer and that she should have co-signed the LVN's assessment.

An interview, on 5/15/12, at 2:45 PM, with the RN, (RN 2), who was supposed to provide oversight of the LVN on 5/14/12, when Patient 3 was admitted, was conducted. He stated that he did not assess Patient 3's sacrum pressure ulcer and that it was the responsibility of the admission nurse to co-sign for the LVN.

28020



Based on interview and record review, the facility failed to ensure that the nursing staff develops and keeps current a plan of care that adequately reflected 4 of 13 sampled patients (Patient 3, 5, 1 and 4), needs and interventions regarding pressure ulcers.
1. For Patient 3, the plan of care was not revised to reflect a pressure ulcer on the sacrum (tailbone) region.
2. For Patient 5, the plan of care did not reflect a pressure ulcer on the coccyx (tailbone region) and both heels. The facility failed to ensure that Patient 5's plan of care reflected the physicians plan for Patient 5's care needs.
3. For Patient 1 the plan of care did not have measureable goals or an evaluation of the care plan's effectiveness.
4. For Patient 4, the facility failed to ensure that the "Altered Skin" care plan, dated 5/1/12, was individualized to reflect the status of the patient's right heel pressure ulcer and/or to reflect the interventions to be provided to ensure the needed treatment and continuity of care.
These failures contributed to the patients not having the optimal care to meet their highest level of well being.

Findings:

1. A record review on 5/17/12, at 9:15 AM, of Patient 5, indicated that the patient was admitted on 4/27/12, with a diagnosis of a hip fracture. Patient 5 had surgery on 4/30/12, to repair the fracture.

A record review was conducted on 5/17/12, at 9:35 AM, of Patient 5's medical record. The medical record indicated that on 5/1/12, a Registered Nurse identified a "Stage 1 Pressure ulcer." Patient 5's care plan had no documented evidence to indicate that a care plan was developed to address the pressure ulcer that was identified on 5/1/12.

A record review, on 5/17/12, at 9:35 AM, of Patient 5's physician orders, dated 5/1/12, at 4:10 PM, indicated that the physician ordered a "Wound Care Evaluation" and "Triad Paste" (a protective barrier cream), to be used on the ulcer twice a day and as needed. A review of Patient 5's care plan did not reflect Patient 5's needs and was not consistent with the physician's medical plan for Patient 5.

An interview, on 5/17/12, at 9:35 AM, with the Medical Surgical/Telemetry Charge Nurse was conducted. He indicated that Patient 5's care plan did not reflect the Stage 1 pressure ulcer on the sacrum area that was identified on 5/1/12 and did not include the physician's orders from 5/1/12, which indicted to apply triad paste twice a day and as needed.

A record review, on 5/17/12, at 10:25 AM, of Patient 5's "Wound Assessment/PhotographicWound Documentation," dated 5/5/12 and 5/6/12, indicated that the patient had a pressure ulcer on the coccyx, left heel and the right heel.

A record review, on 5/17/12, at 10:25 AM, of Patient 5's care plan, developed on 4/30/12, had no documented evidence that nursing revised the care plan to reflect Patient 5's condition and needs.

A record review, on 5/17/12, at 10:40 AM, of Patient 5's physician orders, dated 5/6/12, indicated that the physician ordered as a result of the wounds to the sacrum and both heels, a "Wound Care Evaluation, skin prep before application of adhesive or comfeel (dressing), dietary evaluation, triad paste..." A review of Patient 5's care plan, showed no documented evidence that the care plan reflected the physician's plan for the medical care of Patient 5.

An interview, on 5/17/12, at 10:40 AM, with the Medical Surgical/Telemetry Charge Nurse. After reviewing Patient 5's assessments, physician's orders and care plan, the nurse stated that the care plan was not revised to reflect Patient 5's care needs and condition. As of 5/17/12, the Charge Nurse stated that Patient 5's care plan had not been revised to reflect the stages of the pressure ulcers or the physician's orders.

2. A record review, on 5/15/12, at 11 AM, indicated that Patient 3 was admitted to the telemetry floor (a unit that provides cardiac monitoring), on 5/14/12, with a diagnosis of congestive heart failure (heart disease).

A record review, on 5/15/12, at 11 AM, of Patient 3's initial "Wound Assessment and Photographic Wound Documentation," dated 5/14/12, at 4:30 PM, indicated that a LVN (Licensed Vocational Nurse) performed the initial skin assessment of Patient 3. The picture showed a large red pressure ulcer around Patient 3's coccyx area with a small open sore (Stage 2).

A record review, on 5/15/12, at 11 AM, of Patient 3's physician orders (not dated or timed), indicated that Patient 3 had a Stage 2 pressure ulcer. The orders read to cleanse the pressure ulcer with normal saline and apply comfeel (pressure ulcer dressing) to the wound every 2 days.

An interview and a concurrent record review, of Patient 3's medical record, was conducted with the ICU RN for Patient 3, on 5/15/12, at 11:45 AM. After reviewing Patient 3's record, she stated that the plan of care did not address the open pressure ulcer on Patient 3's coccyx area. The plan of care did not include the physician's orders for treating the pressure ulcer.

A record review, on 5/17/12, at 2 PM, of the facility policy titled, "Plan for Provision of Patient Care, revised on February 2011," documented the following: "Patients are entitled to receive safe care which reflects an ongoing use of the Nursing process based on their specific care needs...This plan will be individualized, multidisciplinary, and continually evaluated and adapted as patient needs change...Nursing interventions will be performed in response to identified problems/needs and referrals to other disciplines made as necessary...The plan of care is individualized and includes priorities and the prescribed approaches or measures to achieve goals derived from the nursing diagnosis; i.e., to promote, maintain, and restore the patient's well-being and includes: physiological measures; teaching/learning measures; therapeutic environment; and available resources..." The policy also indicated and guided nurses to include measurable patient goals and to evaluate responses to interventions.

A record review, on 5/18/12, at 4 PM, of Patient 5's care plan developed on 4/30/12, for "Altered Skin," did not include measurable patient goals and outcomes and did not include evaluation of the patient response to interventions.



25179

3. A review on 5/15/12 of Patient 1's medical record showed that the patient was admitted to the facility on 1/23/12 with a diagnosis of Sepsis (systemic infection in which bacteria are present in the circulating blood, having spread from a primary site of infection to any other part of the body). It was documented that the patient was admitted with an unstageable pressure ulcer (bedsore that the base of the wound is covered with yellow or brown non viable tissue or eschar-black non viable tissue) on her left heel, a stasis ulcer (a wound caused by impaired circulation) on her left leg and a stage 3 pressure ulcer (full thickness tissue loss and subcutaneous fat may have been visible but bones, tendon and muscle were not exposed) in her sacrum (bony area above the buttocks).

A review of of Patient 1's care plan showed a plan for "Altered skin" with a goal for "Improved skin integrity, sacral pressure ulcer, left heel pressure ulcer and left lateral (side) leg wound will be monitored and treated appropriately during hospital stay."

There were no measurable goals in the care plan so that the nurses would know what should happen with the pressure ulcers and wound within a timeframe.

There was no evaluation of the care plan goals and interventions to ensure that the current plan was effective.

In an interview on 5/17/12 at 3:45 PM with the Medical/Surgical Director, she acknowledged that the nursing care plan for Patient 1's pressure ulcers and wound should have had measureable goals with periodic evaluations.

A record review, on 5/17/12, of the facility policy titled, "Plan for Provision of Patient Care, revised on February 2011," documented the following: "Patients are entitled to receive safe care which reflects an ongoing use of the Nursing process based on their specific care needs...This plan will be individualized, multidisciplinary, and continually evaluated and adapted as patient needs change...Nursing interventions will be performed in response to identified problems/needs and referrals to other disciplines made as necessary...The plan of care is individualized and includes priorities and the prescribed approaches or measures to achieve goals derived from the nursing diagnosis; i.e., to promote, maintain, and restore the patient's well-being and includes: physiological measures; teaching/learning measures; therapeutic environment; and available resources..." The policy also indicated and guided nurses to include measurable patient goals and to evaluate responses to interventions.



26500

4. On 5/15/12, a review of Patient 4's closed electronic medical record was conducted with the Director of Medical Surgical/Telemetry Unit (DMSTU).
A review of Patient 4's face sheet was conducted and showed that the patient was admitted to the Medical/Surgical Telemetry Unit on 4/30/12, from the emergency department with diagnoses that included pneumonia (bacterial lung infection). Patient 4 was discharged from the facility on 5/7/12.
A review of the "Wound Assessment and Photographic Wound Documentation," dated 4/30/12 at 9 PM, was conducted and revealed that the patient had a Stage III right heel PU that measured 3 cm x 3 cm x 1 cm. The wound bed color was red, pink and yellow, and the periwound (surrounding tissue) was red. The PU had a foul odor, and the patient had pain to the site when it was touched. A review of the photograph that was taken in the ED revealed a right heel pressure ulcer that consisted of full thickness tissue loss in which the base of the ulcer was covered by slough (unstageable).
A review of the "Wound Assessment and Photographic Wound Documentation," dated 4/30/12 at 10 PM, was conducted and revealed that the patient had a Stage III right heel PU that measured 5 cm x 4 cm x 0.2 cm. The wound bed color was yellow, and the periwound was red. The PU had a mild odor. A review of the photograph that was taken upon admission to the MSTU revealed a pressure ulcer that consisted of full thickness tissue loss in which the base of the ulcer was covered by slough (unstageable).
A review of the Wound/Skin Care Physician Orders, dated 4/30/12, included, wound care- apply santyl ointment (a medication used to remove dead tissue from PU wounds), cover with foam dressing and a dry dressing every 12 hours.
A review of the "Altered Skin," care plan developed for Patient 4 on 5/1/12, showed the following:
Problem- skin problem identified related to right heel wound ...
Goal- Patient's skin integrity will be maintained or improved during hospitalization.
Interventions- reposition every 2 hours; cleanse right heel with wound cleanser then apply santyl ointment and cover with foam dressing and dry dressing daily.
A review of the PO, dated 5/2/12 at 10 AM, showed "daily" dressing change to right heel Stage III PU. The wound orders included, a daily application of santyl 1/8 inch thin layer, "cover with a moistened normal saline gauze," then cover with foam and wrap with gauze dressing.
The "Altered Skin" care plan, dated 5/1/12, was not revised to reflect that the wound care treatment orders changed on 5/2/12.
On 5/17/12 at 11 AM an interview was conducted with the DMSTU. She confirmed that the patient's "Altered Skin," care plan, dated 5/1/12, did not reflect the patient's right heel PU stage. The DMSTU stated that the care plan should have reflected the staging of the PU. She also confirmed that the wound care treatment on the care plan did not reflect the treatment ordered by the physician, dated 5/2/12. The DMSTU stated that the care plan should have been revised to reflect the most current wound care orders. She confirmed that the Altered Skin care plan was not individualized to reflect the patient's status.

Based on interview and record review, the facility failed to ensure that a Registered Nurse who was covering for a Wound Care Nurse and conducting wound assessments of patients, was adequately trained and competent to care for patients who required "Wound Care Evaluations." This failure resulted in 1 of 13 sampled patients (Patient 5), to not receive the appropriate care and necessary services from a Wound Care Nurse, which was ordered by the physician.

Findings:

A record review, on 5/17/12, at 9:15 AM, of Patient 5, indicated that the patient was admitted on 4/27/12, with a diagnosis of a hip fracture. Patient 5 had surgery on 4/30/12, to repair the fracture.

A record review, on 5/17/12, at 10:40 AM, of Patient 5's "Wound/Skin Care Physician Orders," dated 5/6/12, indicated that Patient 5's physician ordered a "Wound Care Evaluation" for the patient.

A record review, on 5/17/12, at 10:55 AM, of Patient 5's "Wound Assessment and Photographic Wound Documentation," dated 5/13/12, at 3 PM, indicated that a RN conducted the assessment however there was no staging of the pressure ulcer.

An interview and a concurrent record review, on 5/17/12, at 10:55 AM, of Patient 5's medical record was conducted with a Medical Surgical/Telemetry Charge Nurse. After reviewing Patient 5's medical record, the Charge Nurse stated that the usual Wound Care Nurse (who had taken time off from work) and who conducted the Wound Care Evaluation of Patient 5, was being covered by a RN who was not a Wound Care Nurse. The Charge Nurse also stated that the reason the RN did not stage the pressure ulcer was because, according to the facility policy, only Wound Care Nurses and physicians, can stage a pressure ulcer. He also stated that the RN who conducted the evaluation, was a floor/staff RN and was not allowed to stage the pressure ulcer. He stated that no "Wound Care Evaluation" was done for Patient 5 by a Wound Care Nurse, until 5/16/12.

An interview and a concurrent record review was conducted on 5/16/12, at 3 PM, with the facility Administrative Assistant, of the personnel file of the RN who performed the Wound Care Evaluation on Patient 5. The Administrator Assistant stated that the RN did not have a job description in her file to indicate that she was competent to perform Wound Care Evaluations.

Based on interview and record review, the facility failed to ensure that a Registered Nurse (RN) did not write a physician order without speaking with and obtaining the order from the physician. This failure contributed to the potential for an increased risk for 1 of 13 sampled patients, (Patient 3), to not receive medical treatment as intended by the patient's primary care physician.

Findings:

A record review, on 5/15/12, at 11 AM, indicated that Patient 3 was admitted to the telemetry floor (a unit that provides cardiac monitoring), on 5/14/12, with a diagnosis of congestive heart failure (heart disease).

A record review, on 5/15/12, at 11 AM, of Patient 3 s initial "Wound Assessment and Photographic Wound Documentation," dated 5/14/12, at 4:30 PM, indicated that a LVN (Licensed Vocational Nurse) performed the initial skin assessment of Patient 3. The picture showed a large red pressure ulcer around Patient 3's coccyx area with a small open sore (Stage 2).

A record review, on 5/15/12, at 11 AM, of Patient 3's physician orders (not dated or timed), indicated that Patient 3 had a Stage 2 pressure ulcer. The orders, read to cleanse the pressure ulcer with normal saline, apply comfeel (pressure ulcer dressing) to the wound every 2 days. The order also included, a wound care evaluation, specialty mattress/pressure redistribution support surface: (Isoflex), reposition every 2 hours as condition permits and to redistribute pressure with pillow/wedges.

An interview, on 5/15/12, at 3 PM, was conducted with the Wound Care Nurse who wrote the physician orders. She stated that it was her first day working at the facility and that she was covering for the facility Wound Care Nurse who had taken some time off from work. She stated that she did write the order but that she had not spoken with the physician. The Wound Care Nurse also stated that she was told by the facility staff, "That's how they do it here."

A record review, on 5/16/12, at 8:25 AM, of the facility policy, titled "Verbal and Telephone Orders, dated September 2011," indicated the following: "...Orders given verbally or by telephone for medications and their administration shall be filled only when given by a qualified physician...All verbal/telephone orders of medication shall be transcribed in writing into the medical chart of the patient form if taken...To prevent medication errors related to verbal/telephone orders, all individuals licensed and approved by this hospital to receive and record these types of orders must strictly observe the following practices when performing this function. The receiver of the order must:...Write down the complete order and then read it back to the prescriber, receiving confirmation from the prescriber that the order is correct...Read the entire order to the prescriber..."

Based on interview and record review the facility failed to ensure that all physician verbal orders for a medication for 1 of 13 sampled patients (Patient 1) were authenticated, creating a potential risk of the patient receiving a medication that was not ordered by the physician.

Findings:

During a review of the medical record for Patient 1 on 5/15/12, the following physician telephone order for a medication was seen without a physician signature, date or time of the signature:

On the Physician ' s Order Sheet dated 5/12/12 there was an order for KCL (Potassium Chloride) 40 meq. (millequivalents) GT (gastric tube-a tube inserted through the abdominal wall into the stomach for feeding and medication administration) X 1 (one time).

In an interview on 5/15/12 at 11:10 AM with the Director of the Medical-Surgical unit, the Director acknowledged that the physician telephone order was not authenticated within 48 hours.

A review of the Medical Staff Rules and Regulations dated 5/12 showed the following:

" All verbal orders for medications shall be signed, dated and timed by the ordering physician within forty-eight (48) hours. "





26881

Based on document review and interview, the facility failed to ensure that a nursing standardized procedure was developed to administer antipyretics, Tylenol (acetaminophen) and Motrin (ibuprofen) to patients of all ages seen in the emergency department (ED). That this procedure was consistent with the requirements for supervision and education as stipulated in the statute, and that the content of the policy matched the actual practice that occurred in the ED.

Findings:

A review of the facility's Departmental Policies and Procedures titled, "Standardized Procedure for Administration of Antipyretic Medications Performed by Emergency Department Registered Nurses" on 5/16/2012 at approximately 2:20 PM outlined the nursing management of a patient in need of antipyretic medications in the ED (Emergency Department).

As documented, the ED nurse would administer either acetaminophen or ibuprofen to a population consisting of pediatric, adolescent, adult, and geriatric patients with a condition having a temperature greater than 101 degrees Fahrenheit.

The policy documented that no supervision was needed by the ED physician. Essentially, the nurse would prescribe and administer the medications according to the policy. The policy indicated that after a nursing assessment, the nurse would determine based on a dosing sheet whether to administer acetaminophen or ibuprofen to the patient. The assessment would include temperature, history of untoward side effects, contraindication to the medication(s), and antipyretics previously administered.

The policy further documented that a collaborative consultation with the ED provider (physician) shall be done, if an assessment indicates presence of a potential contraindication.

During an interview conducted with the director of pharmacy services (DOP) on 5/16/12 at 2:35 PM, he reviewed the policy and reported that he was unaware of the policy titled, "Standardized Procedure for Administration of Antipyretic Medications Performed by Emergency Department Registered Nurses". He acknowledged that the facility's policy was reviewed and approved on 4/2011 and 3/2012 respectively.

During a tour of the Emergency Department, an interview was conducted with the Director of the Emergency Department on 5/16/12 at 3:06 PM. He was shown the policy-nursing standardized procedure. He reported that the practice, that is, following the standardized procedure has been in effect for some time, at least three years. He reported that pediatric through geriatric patients would be triaged and the medication(s) administered if necessary. When asked if newborn patients were included, he reported that they were not.

Further review of the policy with the ED director revealed that patients starting at age zero (0), a newborn with a temperature exceeding 101 degrees F would be administered acetaminophen. If Motrin was administered, the starting age would be an infant age 6-11 months. When asked how often either medication would be administered, the ED director stated that patients are administered only one dose. However, the policy documented that an acetaminophen dose may be repeated every 4 hours, and a Motrin dose may be repeated every 6 - 8 hours. In addition, the facility did not determine a maximum dose for either of the drugs in light of the potential risks surrounding the administration of acetaminophen.

Therefore, the facility failed to ensure that a nursing standardized procedure developed to administer antipyretics, Tylenol (acetaminophen) and Motrin (ibuprofen) to patients of all ages seen in the emergency department (ED) was consistent with the requirements for supervision and education as stipulated in the statute., and that the content of the policy matched the actual practice that occurred in the ED.






26502



26881



28135

Based on observations, record reviews and interviews, the hospital failed to ensure adequate oversight of the dietary service department as evidenced by observations of deficient practices related to 1) safe food handling, and 2) a failure to ensure patient's therapeutic diets were consistent with the physician ordered diets. Failure to ensure adequate oversight of department activities by the director of food services resulted in unsafe food handling that put the patients at risk for food borne illness. It also resulted in the potential for not meeting the nutrition needs of the patients and for further compromise to their medical status.

Findings:

1. During a review of the dietetic services on 5/15/12 and 5/16/12 deficient practices were identified with respect to safe food handling (cross refer A 749) and inconsistency of the physician ordered therapeutic diets and actual diets provided to the patients (cross refer A 629).

In an interview with the Director of Food and Nutrition Services (DFNS) on 5/15/12 at 10:15 am, she stated that the food services supervisor (FSS) had been helping out at another facility for the last two months.

In an interview with the FSS on 5/15/12 at 11:15 am, she stated that she was now the FSS for another hospital but visited the facility one day a week to place the food orders. She also stated that she was training two of the food service workers to replace her.

A review of the facility's plan of correction for a Sample Validation Survey in January 2012, revealed that daily monitoring of the deficient practices identified in that survey was to be initiated on 1/16/12 and documented on a daily monitoring tool. A review of the daily monitoring tool revealed that it was not initiated until 5/9/12.

During an interview with the DFNS on 5/16/12 at 9:15 am, she verified that daily monitoring audits where not started until 5/9/12. She was unable to explain why it was not initiated according to the facility's plan of correction. She also was unable to explain how the deficient practices identified during this survey were not identified on the daily monitoring tool. She stated that various food service workers filled out the tool, but that she did not. She stated that although the FSS had been covering another facility for two months, training of her replacement had only begun about a week ago. The DFNS was unable to explain how safe food handling practices were being monitored while the FSS was covering the other facility.

2. During an interview with the DFNS on 5/15/12 at 3:45 pm, she verified that two of the physician ordered diets were entered into the computer system incorrectly and resulted in two patients receiving restricted diets that were not ordered by the physicians. She was unable to explain how the system of inputting diet orders into the computer was monitored to ensure the accuracy of physician orders. She stated that when the Registered Dietitian (RD) assessed the patients, the diet order was verified at that time. She was unable to explain how the diet orders of patients were verified when the patients were not reviewed by the RD. She verified that a Renal diet was a restrictive diet and different from a Regular diet and that Patient 10 was served a Renal diet when the physician order was for a regular diet. She also verified that Patient 9's physician diet order did not contain a calorie restriction, but the patient was served an 1800 calorie ADA diet.

Based on record reviews and interviews, the hospital failed to ensure that the diets served to 2 of 3 patients reviewed for nutrition care were consistent with the physician ordered diets (Patients 9 and 10). For Patient 9, the physician ordered "Diet as Tolerated, ADA restrictions (diabetic)" and the diet served was an "1800 calorie ADA" diet. For Patient 10 the physician ordered a Regular diet and the patient was served a Renal diet (for patients with impaired kidney function). This failure to ensure that patients received the physician ordered diets had the potential for the nutrition needs of the patient to not be met and further compromise their medical status.

Findings:

1. A review of the medical record for Patient 9 revealed a physician order dated 5/12/12 for "Diet as Tolerated, ADA restrictions." There was no calorie limit element to the diet order.

A review of Food and Nutrition Services Current Diet list showed that Patient 9's diet listed as 1800 Calories ADA diet.

During an interview with the Registered Dietitian (RD) on 5/15/12 at 2:15 pm, she verified that the patient was receiving an 1800 calorie ADA diet. She further verified that the physician's diet order did not specify a calorie restriction. She stated that the order was entered into the computer system incorrectly. She stated that the patient was receiving the incorrect diet order for 3 days. She stated that she monitors the diet orders for the patients that are reviewed for nutrition assessments by the RD, but not the patients who were not considered high nutrition risk. Those patients are not required to be reviewed by the RD until 5 days after they are admitted.

During an interview with RN 1, charge nurse for Patient 9, on 5/15/12 at 2:20 pm, she stated that the diet order had been entered in the computer system incorrectly. It should have entered as "ADA, Calories Not Specified". She was unable to explain why the incorrect diet order was not noted for 3 days

2. A review of the medical record for Patient 10 revealed that there was a physician order for a Regular diet on 5/7/12.

A review of Food and Nutrition Services Current Diet list showed that Patient 10's diet listed as Renal diet. Renal diets are restricted in sodium, potassium and phosphorus for patients with impaired kidney function.

During an interview with the RD on 5/15/12 at 3:30 pm, she verified that the patient was receiving a renal diet since 5/13/12. She stated that the patient should have been receiving a regular diet. She stated that the incorrect diet was entered in the computer system.

During an interview with RN 1, charge nurse for Patient 10, on 5/15/12 at 3:45, she was unable to explain why the order in the computer was changed from a regular to a renal diet when the physician order did not change. She was also unable to explain why the error was not noted for two days.

Patient who receive inaccurate diets are at risk for nutritional deficits, especially when the diets served are more restrictive than the physician order.

28135



Based on observation, record reviews and interviews, the hospital failed to ensure that there were infection control measures in place to prevent the development of food borne illness and cross contamination in the food service departments. The hospital failed to have a thorough infection control surveillance system that monitored the conditions and practices of the dietetics services staff. By not having these measures and a thorough surveillance system, potentially hazardous foods had been stored, prepared and distributed under unsafe and unsanitary conditions and there was potential for such continuation in the absence of identification and remediation.

Findings:

1. During the initial tour of the kitchen on 5/15/12 at 9:30 am, a pan containing 2 turkey breast roasts were observed in the walk-in refrigerator. The pan was partially covered with plastic wrap and dated "5/14/12 - 5/17/12". The temperature of the two roasts registered 41.5 ºF (Fahrenheit) and 40.8 ºF respectively.

During a concurrent interview with the Director of Food and Nutrition Services (DFNS), she stated that the two roasts were cooked on 5/14/12. They were to be served to patients for dinner on 5/15/12.

During a review of the hospital's Cooling Logs for 5/14/12, there was no temperature monitoring documented for the turkey roasts.

During further interview with the DFNS, same date and time, she stated that Cook 1 cooked the roasts on 5/14/12. She was unable to explain why the Cooling Logs didn't contain documentation of the temperature monitoring for the cooling of the roasts.

During an interview and document review with Cook 1 on 5/15/12 at 10:40 am, she produced a Cooling Log labeled "Turkey 5/14/12" that was stored in the steamtable, not with the rest of the Cooling Logs. The log indicated that the cooling temperature monitoring was initiated at 4:30 pm with the turkey breasts at 165 ºF. It stated that the 2 Hour Temperature was 68 ºF. Cook 1 stated that the 2 hour temperature was taken at 6:30 pm. She stated that she then put the roasts in the walk-in refrigerator and did not monitor the temperature further. She stated that as long as the temperature was 70 ºF or below at 2 hours, then it didn't require further monitoring.

According to the 2009 FDA Food Code, cooked, potentially hazardous food shall be cooled within 2 hours from 135 ºF to 70 ºF, and within a total of 6 hours from 135 ºF to 41 ºF. It further states that if food is not cooled in accordance to this Code requirement, pathogens may grow to sufficient numbers to cause foodborne illness.

When there is a lack of documented monitoring of the cooling of potentially hazardous foods, there is no way to ensure that the food was safely cooled within the timeframes required. Therefore there is no way to ensure the food is safe and will not cause food borne illness.

Further review of the hospital's Cooling Logs dated 5/7/12 showed an entry for Eggplant Stew and the starting temperature was 106 ºF. Another entry dated 5/13/12 for Picadilli (a ground beef based casserole) and the starting temperature was 100 ºF. Both entries indicated that the food was served after improper cool down monitoring occurred.

During an interview with the Food Service Supervisor on 5/15/12 at 11:15 AM, she verified the entries and stated that safe cool down temperature monitoring should have been started when the food was 135 ºF or higher. She verified that when monitoring started at 100 ºF or 106 ºF there was no way to ensure that the food cooled from 135 ºF to 70 ºF in the required two hour timeframe.

According to the 2009 FDA Food Code, "The initial 2-hour cool is a critical element of this cooling process."

According to the facility's plan of correction for the January 2012 sample validation survey, daily monitoring of the cooling logs was initiated on 1/16/12 and documented on a daily monitoring tool. A review of the daily monitoring tool revealed that monitoring of the cooling logs did not begin until 5/9/12, not 1/6/12. It also revealed that the Picadilli entry on the cooling logs was not noted to be out of compliance. The monitoring tool did not indicate that there was any problem with the process of initiating the cool down monitoring at 100 ºF instead of 135 ºF.

2. During the initial tour of the kitchen on 5/15/12 at 9:10 am, a five pound container of chicken salad was observed with a manufacturer's "use by" date of 5/12/12. Also observed was a five pound container, approximately two thirds full, of pasta salad with a manufacturer's "use by" date of 5/13/12. The pasta salad also had an open date of 5/14/12, indicating that it was opened and used the day after the "use by" date.

During a concurrent interview with the Registered Dietitian (RD) she verified the findings and stated that the two products should have been discarded on the "use by" dates.

According to the facility's plan of correction for the January 2012 sample validation survey, daily monitoring of expired foods was initiated on 1/16/12 and documented on a daily monitoring tool. A review of the daily monitoring tool revealed that monitoring of expired foods did not begin until 5/9/12, not 1/16/12. Also according to the monitoring tool, the above expired product was not noted by the hospital prior to the surveyor's observation, despite daily monitoring.

3. During the initial tour of the kitchen on 5/15/12 at 9:15 am, the table mounted can opener in the cooks area was observed with the blade worn and nicked.

According to the 2009 Food Code, cutting or piercing part of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is open. It further stated that multiuse food contact surfaces shall be smooth and free of crevices. Surfaces which have imperfections such as cracks, chips or pits allow microorganisms to attach and form biofilms that can release pathogens in the food. Biofilms are highly resistant to cleaning and sanitizing efforts.

During a concurrent interview with Food Service Worker 1 (FSW 1), she stated that the can opener blades were changed monthly. She verified that the can opener blade was worn and nicked and needed to be changed. She was unable to state when the last time the blade was changed. She stated that she changed the blade on the can opener in the cold prep area on 5/11/12. She did not know why the blade was not changed on the can opener in the cook's area.

A review of the hospital's "Can Opener Blade Monitoring Tool" dated 3/14/12 through 5/11/12 showed that the can opener blade was changed on 5/11/12.

During an interview with the DFNS on 5/15/12 at 9:40 am, she stated that she had one log to monitor the two can opener blades. She was unable to explain why the log indicated that the blade on the can openers had been changed when the blade in the cook's area was not changed.

According to the facility's plan of correction for the January 2012 sample validation survey, daily monitoring of can opener blade integrity was initiated on 1/16/12 and documented on a daily monitoring tool. A review of the daily monitoring tool revealed that monitoring of the can opener blade integrity did not begin until 3/14/12, not 1/16/12. Also according to the monitoring tool, the worn, nicked blade of the can opener was not noted by the hospital prior to the surveyor's observation, despite daily monitoring.

4. During the initial tour of the kitchen on 5/15/12 at 10:20 am, multiple items in the walk-in freezer were observed removed from their original packaging and not dated:
· two bags of chicken cordon bleu, individual portions
· a bag containing an large roast approximately 7 - 10 pounds
· a bag of chicken pieces
· multiple cuts of meat individually wrapped
· a bag of frozen shrimp
· multiple containers of soup

During a concurrent interview with the DFNS, she was unable to explain how the staff was able to determine the shelf life of these items when they were not dated.

A review of the hospital's policy titled, "Food Labeling and Dating" dated 9/11, revealed that, "All prepared food and food stored out of the original container must be covered and labeled as to its content with the shelf life expiration date displayed. It further stated that the product shelf life for frozen goods was 6 months.

There was no way to determine how long the products had been stored in the freezer without date monitoring.