HospitalInspections.org

Based on observation, interview and record review Hospital A failed to ensure that nursing care plans were updated for 2 of 49 sampled patients (11, 12) when the patients developed an infection that required isolation.

Findings:

1. Patient 11 was admitted to the hospital on 6/24/11 for treatment of injuries sustained when he was hit by a bus as a pedestrian. Patient 11 was first observed in the Post Anesthesia Care Unit (PACU) on 9/6/11 at 1:30 P.M. Patient 11 was recovering from anesthesia after under going a reconstructive surgical procedure. The patient was in the isolation room of the PACU. His PACU RN was just outside the door to the isolation room.

An interview was conducted with the PACU RN on 9/6/11 at 1:32 P.M. The PACU RN stated that Patient 11 had sustained burns to 25% of his lower extremities as well as a degloving injury (avulsion of an extensive section of skin. The skin is completely torn off the underlying tissue) from the waist down. The RN stated that Patient 11 had developed a Methicillin Resistant Staphylococcus Aureus (MRSA, a strain of bacteria that becomes resistant to many antibiotics) infection in both lower extremities. The RN further stated that she wore a gown and gloves when caring for Patient 11 but did not need to wear a mask because MRSA is not an air born bacteria.

A general observation tour of the Burn Unit was conducted on 9/7/11 at 8:55 A.M. A sign was observed on the door of Patient 11's hospital room. The sign read "Stop - Contact Precautions" (precautions designed to prevent transmission of infection by skin to skin contact).

A review of Patient 11's medical record was conducted on 9/7/11 at 9:00 A.M. There was no documentation in the patient's nursing care plan that he was in contact isolation for a MRSA infection. Because there was no nursing care plan for Patient 11's infection and isolation, there were no nursing interventions noted.

An interview was conducted with the Assistant Registered Nurse (RN) Manager (ARNM) of the Burn Unit on 9/7/11 at 9:10 A.M. The ARNM stated that it was her expectation to see MRSA and isolation addressed in Patient 11's nursing care plan.

A review of Hospital A's policy and procedure entitled "Nursing Plan for the Provision of Care" indicated that "The (nursing) plan will be evaluated and revised based on the changing needs of the patient. This frequency is contingent on the urgency of the patient's condition and unit standards. Another hospital policy and procedure entitled "Health System Plan for the Provision of Patient Care" indicated that "Based on the initial and ongoing assessments of the patient, an appropriate (nursing) plan of care is developed collaboratively by the clinical disciplines and is documented in the medical record. This plan of care is communicated to all other disciplines and is reviewed and updated as appropriate".

2. Patient 12 was admitted to the hospital on 6/26/11 after sustaining burns to 40% of his face and upper body when a water heater exploded. A review of Patient 12's medical record was conducted on 9/7/11 at 9:35 A.M. There was no evidence in Patient 12's nursing care plan that he had any infection or that he was in any type of isolation.

An interview was conducted with Patient 12's Registered Nurse (RN) on 9/7/11 at 9:45 A.M. The RN stated that Patient 12 was placed in contact isolation (precautions designed to prevent transmission of infection by skin to skin contact) the day before on 9/6/11 for an enterobacter infection (a bacteria commonly found in the intestines). The RN further stated that he had not updated Patient 12's care plan to reflect the nursing interventions required since Patient 12 had been placed in contact isolation.

A review of Hospital A's policy and procedure entitled "Nursing Plan for the Provision of Care" indicated that "The (nursing) plan will be evaluated and revised based on the changing needs of the patient. This frequency is contingent on the urgency of the patient's condition and unit standards. Another hospital policy and procedure entitled "Health System Plan for the Provision of Patient Care" indicated that "Based on the initial and ongoing assessments of the patient, an appropriate (nursing) plan of care is developed collaboratively by the clinical disciplines and is documented in the medical record. This plan of care is communicated to all other disciplines and is reviewed and updated as appropriate".





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