HospitalInspections.org

Based on record review, interview and observations, the facility failed to meet the Condition of Participation for patient rights to receive care in a safe setting:

The findings are:

A. The facility failed to ensure that patients had an appropriate call light and the call light was within reach to alert staff of needed assistance, provide incontinent care and proper medical devices for (P9patient) 4, P7, P10) Refer to tag A-0144

B. The facility failed to ensure that 1 (P(patient)9) of 10 (P1-P10) were monitored for safety while in restraints. Refer to tag A-0175.

Based on record review, interview and observations, the facility failed to meet the Condition of Participation to ensure Licensed Nurses are adhering to policies and procedures.

The findings are:

A. The facility failed to apply medical device as ordered for heel protection. Refer to tag A - 0398

Based on record review, observation and interview, the facility failed to meet the Condition of Participation of adhering to an infection control program to prevent the potential spread of hospital acquired infections (HAIs). This failed practice could cause the spread of infection for all patients of this facility.

The findings are:

A. The facility failed to adhere to an infection control program to prevent the transmission of antibiotic resistant infections. Refer to Tag A-0750

Based on observation, record review and interviews, the facility failed to provide access to an appropriate call light 1 (P (Patient) 4) of 10 (P1-10) patients. These deficient practices can lead to a delay in care, the development of pressure injuries, worsening of wounds, infections and possible death for all patients of this facility.

A. Record review of P4's medical record under History and Physical dated 03/06/2024, P4 was admitted with wounds on sacrococcygeal (area between lower back and tail bone), abrasions (area damaged by scraping or wearing away of skin) to both legs, and pressure injuries (injury to skin and underlying tissue resulting from prolonged pressure on the skin) on both heels. Also, diagnosis of Hypoxic (no oxygen to the brain) brain injury, Septic Shock (A widespread infection causing organ failure and dangerously low blood pressure): pneumonia (lung inflammation) on IV (in vein) antibiotics until 03/23/24, Ischemia (dying of the cells) digits of hands and feet. Incontinent of bowel and bladder.

1. P4 was dependent and unable to verbalize needs and required two (2) staff members to provide incontinent care and repositioning.

B. During an observation on 04/02/2024, from 10:00 am to 11:15 am, P4 yelled and banged his/her hand on siderail to get assistance. Seven (7) staff (S) members #6, #10, #11, #12, #14, #15 and #16 walked past P4's room and did not acknowledge the patient or check on P4's needs.

C. During an observation on 04/02/2024, at 10:40 am, S12 Registered Nurse (RN) stopped in P4's doorway and told P4, "stop you're going to hurt yourself" and kept going down the hall.

D. During an observation on 04/02/2024, at 11:12 am, S16 Certified Nurse Assistant (CNA) stopped at P4's doorway and asked, "What do you need?" and applied a gown used as protective equipment and went into room, S16 went to the bedside and asked, "What do you need?" P4 stated "Water" S16 stated, "You can't have water, but I will get you some ice chips."

E. During an observation on 04/02/2024, at 11:15 am, S15 Licensed Practical Nurse (LPN) gowned up along with surveyor and entered the patient's room. The surveyor observed P4's call light laying on the floor out of reach. S15 checked for incontinence and found P4 to be incontinent of urine and bowel. S15 stated "You need to be changed I'll get your tech and have them change you".

F. During an interview with S15 on 04/02/2024 at 11:18 am when asked if the call light should be on the floor, S15 confirmed that the call light should not be on the floor and should be where the patient can access it. S15 picked the call light off the floor and placed it on the bed. Asked S15 if the facility has call lights for patients that cannot use their hands or fingers. S15 confirmed that they have call lights that patients can use with their head or elbows to call for assistance.

G. During an interview and observation on 04/02/2024 at 11:21 am with P4, when asked if able to call for assistance with the call light, P4 stated "No" and showed her hands with both being black, hard with necrosis (death of tissue) and patient was not being able to move them.

Based on record review and interview the facility failed to ensure that 1 (P (Patient) 9) of 10 (P1-10) patients were monitored for safety and assessed for other interventions while in restraints as evidenced by a lack of documentation within P9's flowsheets. This deficient practice can lead to discomfort, indignity, injury, and being restrained when it is no longer indicated for all patients requiring restraints at this facility.

The findings are:

A. Record review of P9's medical record of a document titled: "RESTRAINT INITIATION/ORDER (NON-VIOLENT NON-SELF DESTRUCTIVE BEHAVIOR)" revealed an order to restrain P9 with soft limb restraints (soft foam wrist or leg holders that restrict movement that would cause pulling of lines/tubes, cause self injury, or disrupt life-saving treatment) dated 07/31/23 at 0001 am (12:01 am). This order was valid for up to seven (7) days.

B. Record review of P9's medical record of document titled: "RESTRAINT MONITORING (NON-VIOLENT, NON-SELF DESTRUCTIVE BEHAVIOR)", dated 08/03/23, time period "1100" (11:00 am) through "1700" (5:00 pm), revealed: "Safety Checks and Monitoring (at least Q 2 Hours) [every 2 hours]: Initial when intervention performed". There were no initials in spaces provided-indicating that the tasks were not completed for the following interventions: 1) Range of motion; 2) food/fluids offered; 3) toileting offered; 4) dignity/comfort/hygiene maintained; 5) managed safety/no injury; 6) mental status unchanged; 7) skin integrity unchanged; 8) temporary release during care giving direct observation maintained of restrained extremities by Registered Nurse ((RN) only); 9) pain managed per policy (RN (Registered Nurse) only). The record did not contain any documentation that the restraints were temporarily released for range of motion, observation or safety checks on 08/03/23 from 11:00 am through 5:00 pm.

C. Record review of P9's medical record of document titled: "RESTRAINT MONITORING (NON-VIOLENT, NON-SELF DESTRUCTIVE BEHAVIOR)", dated 08/04/23, time period "0700" (07:00 am) through "1700" (5:00 pm), revealed: "Safety Checks and Monitoring (at least Q 2 Hours): Initial when intervention performed". There were no initials in spaces provided-indicating that the tasks were not completed-for the following interventions: Circulatory status of restrained extremities by RN only; pain managed per policy RN only. The record did not contain any documentation that the restraints were temporarily released for range of motion, observation or safety checks on 08/04/23 from 7:00 am through 5:00 pm.

D. Record review of the facility's policy titled "CORE [the part of something that is central to its existence]: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion" "H-PC 07-009" "release date: 06/2023" revealed: "Ongoing Safety Checks & Monitoring (at least every two hours or as noted on the designated forms) by the patient's clinical team ...visually observe the patient at least every 2 hours for safety needs."

E. During an interview on 04/04/24 at 2:45 pm with Staff (S)8 Licensed Practical Nurse, S8 confirmed that the safety checks, interventions, restraint monitoring and flowsheets are to be completed by the patient's nurse (Registered Nurse or Licensed Practical Nurse) every 2 hours. The facility failed to ensure that the safety checks and interventions were completed as evidenced by a lack of documentation within P9's flowsheets.

Based on observations, recorded review and interviews the facility failed to ensure Licensed Nurses are adhering to policies and procedures when caring for 1 (P[patient]4) of 10 (P1-P10) patients reviewed. This deficient practice could lead to pain and infections to all patients at risk for skin breakdown (open areas of the skin).

A. Record review of the facility's Policy and Procedure titled "Pressure Injury Prevention" dated 02/20/2024, stated "Make sure that the patients' heels don't rest on the bed. Apply heel protection devices as required to prevent heel pressure injuries. The devices should completely off-load pressure from the heels."

B. Record review of P4's medical record, under wound care notes dated 03/07/2024, at 8:33 pm, revealed P4 had a pressure injury (damage to the tissue) to left heel and right heel. Both heels have necrosis (death of tissue).

C. Record review of P4's medica record, under physician orders, an order dated 03/08/2024 at 9:28 am, stated "Heel Offloading Boots: Ensure heels are properly offloaded off of bed surface with heel boots offloading boots at all times."

D. During observations of P4 on 04/02/2024 at 10:00 am to 11:15 am, revealed P4 did not have offloading boots on P4's feet and P4 was rubbing and digging heels into the mattress on the following times at these times.

E. During observation of P4 on 04/02/2024 at 1:00 pm, revealed P4 did not have offloading boots on feet and P4 was rubbing and digging heels into the mattress on the following times at these times.

F. During observation of P4 on 04/02/2024 at 2:30 pm, revealed P4 did not have offloading boots on P4's feet and P4 was rubbing and digging heels into the mattress on the following times at these times.

G. During an Interview with Staff (S) 4 Chief Operations Officer and Registered Nurse on 04/04/2024 at 1:00 pm, S4 confirmed that P4 had an order for off-load pressure boots and that these should be always applied as order states.

H. Record review of the facility's Policy and Procedure titled CORE: Midline Catheter Site Placement, Maintenance and Dressing changes with release date 06/2023 on page 2 of 2 stated, "Midline catheter (tube inserted in the vein for administration of fluids and medications) site care and dressing changes will be performed every 7 days".

I. Record Review of P4's medical records on a form titled "Invasive Procedures Without Sedation" dated 03/15/2024 at 1555 (3:55 pm) it was written that there was a midline placed in P4's right arm.

J. Record review of P4's medical record under physician orders and on the treatment sheet did not reveal an order for care of the midline that was placed on 03/15/2024.

K. During an observation of P4 on 04/02/2024 at 11:15 AM, 1:00 pm, revealed P4 had a midline in place with the dressing dated 3/15/2024, indicating that the dressing had not been changed since insertion (placement of the midline).

L. During an observation of P4 on 04/02/2024 2:30 pm, revealed P4 had a midline in place with the dressing dated 3/15/2024, indicating that the dressing had not been changed since insertion (placement of the midline).

M. During an observation of P4 on 04/04/2024 at 1:00 am, revealed P4 had a mid-line in the right forearm that had a dressing covering that was dirty and peeling away from the skin and not dated.

N. During an interview on 04/04/2024 at 1:00 pm with S4, S4 confirmed that there were no care orders for the midline in P4's chart. S4 also confirmed that the nurses would not know to care or how to care for the midline without an order.

Based on record review and interviews facility failed to have medical records that show all aspects and completion of care provided for 3 (P (patient) 4, P7, P10) of 10 (P1-P10) patients. This deficient practice could lead to inadequate care for patients related to lack of documentation.


The findings are:

A. Record review of P4's medical record on 04/04/2024 at 10:19 am under areas titled hygiene and output revealed the record did not
contain any documentation of incontinent care or output provided to P4 on 04/02/2024.

B. Record review of P7's medical record under incontinent care and output the record did not contain any documentation in this area of the chart.

C. Record review of P10's medical records under incontinent care and output the record did not contain any documentation in this area of the chart.

D. During an interview with S4, Chief Operations Officer on 04/04/2024, at 10:19 am, regarding P10, S4 confirmed that incontinent care should have been documented. Staff are required to chart incontinence episodes and hygiene. S4 confirmed there is no documentation of chux (waterproof barrier pad) changes, bed changes or incontinent hygiene.

E. During an interview with S17 RN Educator on 04/04/2024 at 10:36 am, regarding P10, S17 confirmed the record did not contain any
documentation for patient receiving incontinent changes or hygiene.

F. During an interview with S17 on 04/04/24 at 12:14 pm, S17 confirmed the record did not contain any documentation of P7 having
incontinent hygiene.

Based on record review, observation and interview, the facility failed to ensure that staff adhere to the infection control precaution program to prevent transmission of antibiotic resistant infections for 1 (P (patient)12) of 12 (P1-P12) patients reviewed. This failed practice could lead to infection for patients of this facility as result of exposure to antibiotic resistant infections.

The findings are:

A. Record review of P12's medical record in laboratory results section revealed:

1. "Culture, Sputum/Lower Respiratory" specimen (a sample of the patient's sputum is obtained, a culture is a test to find if there are germs that can cause an infection, a sensitivity test checks to see what kind of medicine will work best to treat the infection) collected on 12/11/2023. "Result: Heavy growth of Pseudomonas aeruginosa [a type of germ that can cause infections]". The culture indicated P12's strain of Pseudomonas aeruginosa was resistant to 2 of 8 antibiotics tested. In other words, of the 8 medicines tested to see if they would be effective against the Pseudomonas aeruginosa, there were 2 that would not work.

2. "Culture, Sputum/Lower Respiratory" specimen collected on 02/10/2024. "Result: Heavy growth of Pseudomonas aeruginosa..." The culture indicates that P12's strain of Pseudomonas aeruginosa is now resistant to 7 of 12 antibiotics tested. In other words, the number of antibiotics that would not work to treat P12's type of Pseudomonas aeruginosa has now increased to 7 of 12 medicines tested.

B. During an observation of P12 on 04/04/24 at 2:55 pm, revealed P12 sat in the hall in front of their hospital room. A sign indicated P12 was on "Contact Isolation" (isolation techniques for patients with diseases caused by microorganisms that are spread through direct and indirect touching.) There was a small sign that indicated P12 had carbapenem-resistant Pseudomonas aeruginosa ((CRPA)-a strain of bacteria that is resistant to several antibiotics and can be transmitted by direct contact with an infected person or by contact with contaminated items.) Staff, patients, and visitors were frequently walked by P12 at a close distance, there was approximately five (5) feet between P12 and the nurse station counter. P12 was not wearing any personal protective equipment (PPE) such as a mask or a gown. Nursing staff walked around P12 in the hall were not wearing PPE either.

C. During an interview on 04/04/24 at 3:00 pm, with Staff (S)10 Infection Preventionist, S10 reported P12 was colonized (spread of a microorganism like a bacteria in a new area of the body or an overgrowth of a microorganism in an area in the body) with CRPA and Multi-drug resistant organism (MDRO) (an antibiotic resistant bacteria) Pseudomonas in the sputum. S10 confirmed P12 was colonized with a particularly virulent strain of CRPA. S10 confirmed P12 was allowed to sit in the hall without PPE.

D. Record review of Centers for Disease Control and Prevention (CDC) "Healthcare-Associated Infections (HAIs)" "CRPA Carbapenem-resistant Pseudomonas aeruginosa: A Serious Public Health Threat!" pamphlet revealed: "Patients colonized with CRPA can be a source of spread to other patients and develop CRPA infections. Because patients colonized with CRPA do not have signs or symptoms of infection, they can go undetected and contribute to silent spread of resistant bacteria." "Protect your patients by wearing a gown and gloves for patient care according to the guidelines for your setting (i.e., Contact Precautions in acute care ...) Clean and disinfect the patient environment."

E. Record review of the facility's policy "CORE [central to the existence of]: Transmission-Based Precautions H-IC 02-002" "Release Date: 06/2022," revealed:

1. "2. Contact Precautions: Contact precautions is a method designed to reduce the risk of transmission of microorganisms by direct or indirect transmission. Contact Precautions are used for patients with known or suspected infections or evidence of syndromes that represent an increased risk of contact transmission.

2. "D. Care Considerations Related to Patient Transport and Use of Common Areas: 1. Patients are not to be strictly confined to their room, though movement and transport of the patient from the room should be limited to medically necessary purposes .... 4. Contact Precautions should be maintained by covering or by containing the site of infection or colonization, using appropriate barriers on the patient, such as impervious dressings to cover infectious skin lesions or drainage."