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Based on observation, medical record review, policy review and staff interview, the facility failed to ensure that nursing staff evaluated nursing care for three of 12 medical records reviewed (Patient #1, #9, #12). The facility census was 637.

Findings include:

1. Patient #1 presented to the Emergency Department of the facility's North Campus by ambulance on 05/02/19 at 10:44 AM with complaints of a fall at home and mental status changes. The patient was admitted to a medical surgical unit for treatment of urinary tract infection with sepsis, acute alteration in mental status, and open wound of anterior abdominal wall. According to the intake and output flowsheet an indwelling Foley catheter was inserted on 05/02/19 at 6:53 PM. A physician progress note stated the registered nurse (RN) that inserted the indwelling catheter reported the urine "looked cloudy, purulent and bloody." The progress note further stated, "this is likely the source of the patient's infection and etiology of his/her mental status changes." The intake and output flowsheet did not note catheter care was performed until 8:53 AM on 05/04/19, more than 36 hours after being inserted. The medical record lacked documentation that a staff RN performed catheter care again until 12:34 AM on 05/07/19. The catheter was removed on 05/07/19 at 1:19 PM.

The facility's 2019 Infection Prevention and Control Plan was reviewed on 07/02/19 at 2:20 PM. The plan instructed staff that routine urinary catheter care is essential to reduce risk for infection and urinary catheter obstruction and/or malfunction that could result in a range of complications. The plan further instructed staff to perform catheter care daily and as needed. Staff A was interviewed on 07/02/19 at 3:00 PM. It was confirmed the medical record lacked documentation catheter care was performed daily as required.

2. Staff E was observed performing a physician ordered straight catheterization for Patient #12 on 07/02/19 at 3:00 PM. After completing the catheterization, gathering used supplies, including betadine swabs, and urine, Staff E transported them to the bathroom. The urine was poured into a container to measure the urine. Staff E removed and disposed of gloves and exited the bathroom. The staff member then put on a pair of disposable gloves retrieved from a glove box to continue patient care. There was no hand hygiene performed by Staff E after removal of the gloves.

The facility policy for hand hygiene, effective 02/14/19, was reviewed on 07/02/19 at 4:00 PM. According to the policy, hand hygiene should always be done before and after using gloves. These facts were confirmed with Staff A on 07/02/19 at 4:30 PM.

3. The medical record of Patient #9 revealed the patient had a scheduled cerclage procedure (a pursestring stitch used to cinch the upper part of the cervix shut) on 06/03/19 at 7:21 AM The obstetric physician ordered nursing staff to assess the fetal heart rate before and after the procedure. At 7:50 AM the labor flowsheet noted the fetal heart rate was 152-157 beats per minute per doppler. A nurse's note at 9:54 AM stated the patient was in recovery as the cerclage procedure had been successfully completed. At 11:56 AM the labor flowsheet noted a staff nurse performed a straight catheterization. The medical record lacked documentation a physician ordered this procedure. The patient was discharged home from the facility at 1:20 PM. The medical record lacked documentation staff assessed the fetal heart rate after the procedure as ordered by the physician.

The facility protocol/policy titled Intermittent (Straight) Urinary Catheter: Inserting in the Female Adult Patient, written on 04/27/18, was reviewed on 07/02/19 at 9:00 AM. According to the policy, intermittent catheterization, also called straight catheterization, involves periodic insertion of a catheter into the bladder via the urethra, draining the bladder, then removing once the bladder is emptied. The steps that should be performed before staff undertake a straight catheterization include review of the treating clinician's order for the straight catheterization. Staff C and Staff D were interviewed on 07/02/19 at 10:15 AM. Both staff members stated it was the expectation that staff have a physician order to perform a straight catheterization prior to performing the procedure. It was also confirmed the medical record lacked documentation the fetal heart rate was assessed after placement of the cerclage.