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Based on policy review, clinical record review and interview, it was determined, the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5). This failure affected 4 of 10 sampled patients (Patient #2, #4, #5, and #6) as evidenced by failure to reassess pain as specified in the facility policies and procedures; failure to follow prescription parameters for pain management and failure to administer as needed medications to manage elevated blood pressure and blood sugar.


The findings included:


Facility policy titled "Pain Management" revised 05/01/18 documents "The efficacy of pain management interventions should be continually evaluated and dosages adjusted based on the changing nature of the pain. Pain should be reassessed at least once per shift and when the condition warrants. For those patients having pain, documentation of intervention must occur at least once per shift on the problem list or plan of care. Pain reassessment must be done after each intervention. Pain reassessment will be completed as soon as possible but not to exceed 2 hours. Pain reassessment is documented."


1) Clinical record review conducted on 08/29/18 revealed a Physician's Order for Patient #6 dated 08/09/18, the order documents Vicodin 5/325 mg every six hours as needed for pain level 3-8.

Review of the Medication Administration Records and Assessment and Reassessments documentation indicates the nursing staff administered pain medication on 08/13/18 at 1:41 AM for pain at level 5. The nursing staff failed to reassess the patient's pain level to monitor effectiveness of the drug administration. There is no evidence the pain reassessment was completed within two hours of the pain medication administration.



2) Clinical record review conducted on 08/29/19 revealed Patient #4 was prescribed Hydrazaline 10 mg every 6 hours as needed for systolic blood pressure greater than 160 on 06/05/18.

Blood Pressure (B/P) readings documented for Patient #4 included the following:
On 06/06/18 at 12 AM the B/P was documented as 163
06/0618 at 4 AM B/P 181
06/06/18 at 8 AM B/P 163
06/07/18 at 8 AM B/P 170
06/07/18 at 12 PM B/P 178
06/07/18 at 4 PM B/P 178
06/08/18 at 4 PM B/P 164
06/09/18 at 12 PM B/P 163
06/10/18 at 12 PM B/P 178

Review of the medication administration records and nursing notes failed to provide evidence the nursing staff followed the medication order and administered the Hydrazaline when the blood pressure readings were above 160. There is no documentation of medication refusal or other clinical judgement to omit the doses when the patient's blood pressure met the prescribed parameters.



3) Clinical record review conducted on 08/29/18 revealed a Physician's Order for Patient #4 dated 06/04/18, the order documents Oxyr 5-15 mg every four hours as needed for pain.

Review of the Medication Administration Records and Assessment and Reassessments documentation indicates the nursing staff administered pain medication on 06/05/18 at 4:41 AM for pain. The nursing staff failed to reassess the patient's pain level to monitor effectiveness of the drug administration. There is no evidence the pain reassessment was completed within two hours of the pain medication administration.



4) Clinical record review conducted on 08/29/18 revealed Physician's Orders for Patient #2 dated 05/07/18, the orders document Vicodin 5/325 mg every four hours as needed for pain level 3-7 and Morphine sulfate 1 milliliter every four hours as needed for pain 7-10.

Review of the Medication Administration Records and Assessment and Reassessments documentation indicates the nursing staff administered Morphine pain medication on 05/07/18 at 11 PM for pain level of 6. The nursing staff failed to follow the prescribed parameters for pain management.


5) Clinical record review conducted on 08/29/19 revealed Patient #5 was prescribed Regular insulin sliding scale on 06/05/18 at 4:21 AM, with instructions to give 1 unit of insulin for blood sugar readings of 176-200; 2 units for blood sugar 201-250; 3 units for readings 251-300, 4 units for readings 301-350 and 5 units for readings 351-400.

Glucose monitoring results indicates the patient blood sugar on 06/05/18 at 11:33 AM was 200.

Review of the medication administration records and nursing notes failed to provide evidence the nursing staff followed the medication order and administered the insulin when the blood sugar readings was above 176. There is no documentation of medication refusal or other clinical judgement to omit the doses when the patient's blood sugar met the prescribed parameters.


Interview with The Quality Coordinator who was navigating the electronic record on 08/29/18 starting at 12:30 PM confirmed the findings indicated above.

Based on staff interview and clinical and administrative record review, the facility failed to ensure medications were administered as prescribed by the physician and according to accepted standards of practice for 2 of 4 patients reviewed for medication administration (Patients # 23 and # 24).

The findings included:

The facility's policy regarding Medication Administration Times, Origin Date, May 17, 2018, documented "Medications are to be administered between 1 hour prior and 1 hour post the standard administration time. Standard Medication Administration times chart reflect every 6 hour schedule is 0400, 1000, 1600 (4:00 PM), 2200 (10:00 PM).


1) Review of the clinical record for Patient # 24 revealed the physician prescribed on 08/25/18 for the patient to receive Piperacil/Tazabatam 3.375 G/NS 50 ML Intravenously (IV) every 6 hours. On 08/27/18, the Medication Administration Record (MAR) documented the nurse administered the Piperacil at 4:14 AM, 9:11 AM, 7:03 PM (1903) and 11:56 PM (2356).

An notation received on 08/31/18 by the Quality Manager, who acknowledged the nurse did not adhere to the prescribed schedule because she got busy.

2) Review of the clinical record for Patient # 23 revealed the physician prescribed on 08/28/18 for the patient to receive Morphine Sulfate Sliding Scale IV every 4 hours as needed for Pain Management. Sliding Scale: 3 to 5 give 1 unit (mg); 6 to 10 give 2 Unit (mg). On 08/30/18 at 10:31 AM, the nurse documented she administered MS 4 mg.

An interview was conducted on 08/30/18 at approximately 3:00 PM with the Quality Manager, who confirmed the nurse administered an amount not prescribed by the physician.

Based on staff interview and clinical and administrative record review, the facility failed to provide evidence of following the established standards of practice for blood transfusion regarding monitoring and administration for 1 of 1 patients reviewed for blood transfusion (Patient # 19).

The findings included:

The facility's policy regarding Administering Blood/Blood Component Transfusions documented the following:
"Identification of blood and blood products must be done at the patient's bedside by two licensed professionals. transfusion record."Once identification is complete, both nurses will sign."
"Obtain patient's vital signs within 15 minutes of beginning of transfusion and record."
"Once the blood is verified in the Transfusion Services Department, deliver the blood product to the patient's bedside and initiate transfusion within 15 minutes. If unable to initiate within 15 minutes, return unit to Blood Bank/Transfusion Services."

Review of the clinical record, blood transfusion record for Patient # 19, revealed the staff noted they picked up two units of blood on 08/24/2018 at 11:03 AM. According to the blood transfusion record, the nurse documented one unit of blood transfusion was initiated at 11:10 AM. However, the second unit of blood was not documented as initiated until 11:55 (52 minutes after the blood was removed from the blood bank. The facility failed to produce evidence the 2nd unit was initiated within the established 15 minutes time limit from when the blood was removed from the blood bank. The blood transfusion record documented the 1st unit was initiated at 11:10 AM and was completed at 11:50 AM. The 2nd unit was initiated at 11:55 AM and was completed at 12:20 PM.

Additionally, the 2nd unit of blood, initiated at 11:55 AM, the staff failed to document the full vital signs (temperature) 15 minutes after the initiation of the treatment at 12:10 PM.

A 08/21/18 blood transfusion record failed to document two nurses' signature verifying the identification of the patient and the blood.

An interview with the Nurse Manager on 08/28/18 at 12:50 PM. The NM confirmed the 08/21/18 Blood Transfusion Sheet did not have the signature of two nurses verifying the blood and patient. The 08/24/18 Blood Transfusion Sheet initiated at 11:55 AM did not have a temperature documented at 12:10 PM

Based on observation, staff interview and clinical and administrative record review, the facility failed to adhere to established standards of practice for infection control as evidence by the staff failure to discard biohazard dressing appropriately; failed to follow established infection control practices regarding isolation and hand hygiene standards related to isolation for 1 of 1 patient observed for wound care dressing change ( Patient # 23).

The findings included:

An observation of the wound care dressing change for Patient # 23 was conducted on 08/30/18 beginning at 10:50 AM with the Wound Care Nurse and the Registered Nurse, Staff A. The nurses removed the ace wrap and the Kling wrap on the patient's legs. The remaining 4 x 4 dressings on the left leg were observed to be covered in red colored drainage (blood) on the upper dressing and yellow tinged drainage on the wound dressing on the back of the patient's leg. The wound dressings were noted to have adhered to the the patient's leg wounds, thus the nurses poured normal saline solution over the dressing to loosen the wound dressing adhesion. Upon removing the wound dressing, the WCN discarded the wound dressing with the blood covered 4 x 4 and yellow colored drainage into the regular trash. The staff did not use a red, biohazard bag to discard the dressing. It should also be noted that the patient is on contact isolation.

During the wound care, the patient's physician entered the room wearing an isolation gown and gloves and examined the patient. Upon completion of the examination, the physician exited the patient's room, wearing the isolation gown and gloves and proceeded down the hospital hallway at 11:35 AM. The surveyor, then questioned the staff nurses in the room, "Where was the physician going?" No one expressed an intervention with the physician for not removing his isolation gown, gloves and performing hand hygiene prior to leaving the patient's room.

Furthermore, the WCN was noted on two separate occasions during the wound care dressing change to exit the patient's room after removing her isolation gown and gloves and failed to perform hand hygiene prior to leaving the room. The nurse also went down the hall to retrieve additional supplies, etc. without performing hand hygiene.

An interview was conducted with the WCN following the wound care observation on 08/30/18 at 12:20 PM, who confirmed she exited the room twice without performing hand hygiene. She confirmed there was not a hand sanitizer outside the room to use and she confirmed she exited the room twice to obtain supplies and did not perform hand hygiene. The WCN also stated the wound dressing has to be saturated with blood to be discarded in biohazard. The surveyor then questioned her regarding the noted blood colored staining noted to cover the 4 x 4 dressing on the patient's left leg dressing. Then she stated, "I guess I should have put it in a biohazard bag".

An interview was conducted on 08/30/18 at 2:10 PM with the Infection Preventionist, Infection Control/Safety Coordinator, who stated they consider saturated when you hold up the dressing and "it drips". It doesn't matter the amount. They then stated they follow the Department of Health Guidelines and presented the surveyor a copy of the guidelines.

The guidelines documents "64 E-16.002, Definitions. Biomedical Waste - Any solid or liquid waste which may present a threat of infection to humans, including nonliquid tissue, body parts, blood, blood products, and body fluids from humans and other primates; laboratory and veterinary wastes which contain human disease causing agents; and discarded sharps. The following are also included:
(a) Used, absorbent materials saturated with blood, blood products, body fluids, or excretions or secretions contaminated with visible blood; and absorbent material saturated with blood and blood products that have dried."

However, the facility's policy regarding Biomedical Waste documented as above but included the following also:
"Used, absorbent materials such as bandages, gauzes, or sponges, having the potential to drip or splash, with blood or body fluids from areas as the operating room, delivery rooms and emergency rooms and/or other patient care areas."
"SEGREGATION: Biomedical waste shall be identified and separated from other regular solid waste at the point of origin within the hospital."

Furthermore, the clinical record denotes, the patient is on Contact Isolation secondary to the patient's history of MRSA (Methicillin Resistant Staphylococcus Aureus).

Additionally, the facility's policy regarding Hand Hygiene, revised September 2017 documented, "Hands are to be washed before and after glove use." Gloves are not to be worn as a substitution for hand hygiene and should not be worn outside of patient rooms (i. e. hallways).

The facility's policy regarding Standard Precautions; Isolation/Precaution, revised September 2014 documented, "Gloves and Hand Washing: ..During the course of providing care for a patient, change gloves after having contact with infective material that may contain high concentrations of microorganisms (fecal material and wound drainage). Remove gloves before leaving the patient's environment and wash hands immediately."
Gown: A gown must be worn prior to entering the room. Remove the gown before leaving the patient's environment."

Based on policy reviews and interviews, it was determined, the facility failed to ensure policies governing surgical care included the identification of infected and non-infected cases.

The findings included:

Review of the facility policies and procedures related to surgical services conducted on 08/29/18 and 08/30/18 failed to provide evidence the facility had addressed the identification of infected and non-infected cases during surgical care.

Interview conducted with The Vice President of Quality and Organizational Effectiveness conducted on 08/30/18 at 3:55 PM confirmed there is no written policy addressing infected and non-infected cases in the surgical setting.

Based on record reviews and interview, it was determined, the facility failed to ensure the operating room register was complete. This failure is evident by failure to include the type of anesthesia used during the procedure.

The findings included:

Review of the facility Operating Room Register dated 03/2018 thru 08/2018 revealed the register lacks documentation of the type of anesthesia used during the surgical procedure.

Interview conducted with The Vice President of Quality and Organizational Effectiveness conducted on 08/30/18 at approximately 12:48 PM confirmed the register does not include the type of anesthesia provided.