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Based on observation, interview and record review the facility failed to score patients at risk for skin breakdown appropriately on the Braden Scale to put into place increased nursing interventions for pressure sore prevention. The patients' had documented open wounds, poor nutrition, and limited mobility and still scored for low risk on the Braden Scale for 3 patient's (#5, #6, and #41) of 5 patients. The facility also failed to refer patients for a nutritional evaluation when the patients admission assessment, daily assessment or a laboratory value indicated such a need for 3 of 5 patients. The Braden Scale for predicting pressure ulcer risk is scored according to nursing assessments of each patient (e.g. 15 to 18 Low Risk, 13 to 14 Moderate Risk, and 12 or less High Risk on the 24-hour Assessment Record. The facility census was 112.
Findings included:
1. Observation of Patient #5 on 08/11/10 at 8:45 a.m. revealed a morbidly obese (abnormal accumulation of body fat, usually 20% or more over an individual's ideal body weight) individual with her left foot and right calf covered in bandages from a new surgical procedure.
Record review of the patient's medical chart on 08/11/10 at 9:00 a.m. revealed a diagnosis of Diabetes Mellitus, incontinence, peripheral vascular disease and chair bound but currently on bed rest status. The Patient's laboratory results indicated poor protein levels (can be indicative of poor wound healing ability). The patient's Braden Scale ahould have indicated a patient at hight risk for skin breakdown but instead the patient's score charted for 08/11/10 was 15; indicating Patient #5 is low risk for a pressure sore ulcer.
During an interview on 08/12/10 at 10:30 a.m. Patient #5 stated that he/she had been immobile and wheel chair bound for five years. The Patient denied any other skin issues other than her right leg and left foot.
2. Observation of Patient #6 on 08/11/10 at 9:28 a.m. revealed the Patient with a post operative below the knee amputation (BNA) of the right leg.
Record review of the patient's medical chart on 08/11/10 at 9:45 a.m. revealed a diagnosis of cellulitis (inflammation of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin). Laboratory results did not show testing for albumin or protein which is indicative of nutritional status. The Braden Scores for Patient #6 on 08/11/10 was 18 and 17, indicating the patient is a low risk for pressure ulcers. The Braden Scale should have shown this patient at high risk due to the recent AKA and limited mobility.
3. Closed record review of Patient #41's medical chart on 08/12/10 at 2:00 p.m. revealed an Admission Arrival Sheet with a nutritional assessment indicating the patient should be referred for a nutritional assessment but further review of the Admission Arrival Sheet under "Referral Notified" did not have a check mark for any referrals but was signed, timed, and dated by a Registered Nurse (RN).
4. Closed record review of patient #4's medical chart on 08/12/10 at 2:30 p.m. revealed a diagnosis of cellulitis of the left leg after surgery. The Patient's laboratory results indicate poor protein and albumin levels which can be indicative of poor wound healing ability. The Patient's Braden Scale scores were 21 and 22 with no indication for a nutritional referral. The patient was discharged with several open wounds on the sacrum, an infected wound with MRSA (Methicillin-resistant Staphylococcus aureus (MRSA) infection is caused by a strain of staph bacteria that's become resistant to the antibiotics), and penile necrosis (death of cells
5. During an interview on 08/12/10 at 10:30 a.m. with Staff U, Registered Dietitian (RD) stated that pre-albumin and albumin are the best indicators for nutritional status of a patient. Staff U stated that RD's are supposed to be referred by the nurse's admission assessment, " but that doesn't always happen". He/she stated RD's receive an inpatient list in the morning and then they choose what patient's they need to see. Staff U also stated that there is no care pathway (written procedure for nursing staff) for nutrition. It was stated there are many care pathways available to the nursing staff, but nutrition is not one of them.
6. During an interview on 08/12/10 at 11:00 a.m. with Staff V, RN Educator, Staff W, RN Educator and Staff X, RN, Director of Education stated that the Braden Scale is gone over with nursing staff in orientation but not always on an annual basis. The Educators agreed that there were inconsistencies and concerns in the patient samples presented to them and that further nursing education on the Braden Scale scoring would be necessary. The Staff Educators were also in agreement that a patient's nutritional status was an important part of wound healing and nursing referrals should be made for patients based upon their laboratory values and ongoing patient assessments.
7. Record review on 08/12/10 at 1:00 p.m. of the ASSESSMENT OF PATIENTS AND NUTRITION CARE STANDARDS dated 12/09 revealed, in part:
Purpose:
To define the assessment procedure and nutrition standards by the clinical dietitian for patients admitted to St. Mary's Health Center.
Policy:
The clinical dietitian is responsible for planning the nutritional care of a patient based on the patient's specific needs through the process of screening, assessment and follow up.
Procedure:
1. Nursing Staff completes nutritional screening for all patients within 2 hours of admission. A positive response to any of the screening questions on the " Admission Arrival Sheet " (attachment A) results in a referral to the dietitian.

Based on observation, interview, and record review, the facility failed to ensure scheduled medications were administered according to accepted standards of practice for Patient # 4, # 6. This can lead to increased or decreased effectiveness of medications, affecting patient outcomes. The facility census was 112.
Findings included:
1. Record review on 08/11/10 at 9:28 a.m. of Patient #6's MAR (Medication Administration Record) revealed the medications were ordered for 9:00 a.m. and were not yet administered.
In an interview with Staff OO, RN (Registered Nurse), it was stated that medication administration allowed one hour before to one hour after the scheduled medication time. Staff MM, RN, Nurse Manager stated it was 30 minutes before and 30 minutes after the scheduled medication time.
2. Record review on 08/11/10 at 11:00 a.m. of the MEDICATION: ORDERING, ADMINISTRATION, AND RECONCILIATION INDEX, revealed, in part,
CHAPTER:
F. Administering Medications
4. Right Time
a. Give drug within 1 hour before or after time noted.
3. In an interview on 08/11/10 at 1:10 p.m. with Staff D, RN, Director, Performance Management & Clinical Outcomes, revealed administration is aware that the policy and procedure states medication administration is one hour before and one hour after the scheduled medication administration time. Staff D states administration has been doing studies to find a resolution and is aware that current practice and written nursing policy and procedures are conflicting.
4. In an interview on 08/12/10 at 11:00 a.m. with Staff V, RN Educator, Staff W, RN Educator and Staff X, RN, Director of Education it was stated that they are aware of the conflicts with written nursing policy and procedure and the current accepted standard of practice and haven't yet decided how to handle it for the safety of their patients.


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5. Observation on 8/11/10 at 10:00 a.m. revealed Registered Nurse (RN) I entered Patient #4's room in ICU; donned non sterile gloves and administered seven (7) oral medications.

-Record review of the Medication Administration Record (MAR) revealed all seven (7) medications were ordered to be given daily or at 9:00 a.m. Each medication was initialed but the administration time was documented at 9:00 a.m. and not the time of the observed administration.

-An interview on 8/11/10 at 1:10 p.m. RN I stated the window for administering medications was one (1) hour before and one (1) after the ordered time.

-An interview on 8/12/10 at 10:55 a.m. Director of Education X, stated nursing was taught the window of one (1) hour before and after the ordered times was the policy of the facility.

-An interview on 8/12/10 at 2:45 p.m. Pharmacy Director P stated he/she knew the facility policy on medication administration stated medication can be given from one (1) hour before and after the ordered times.

6. Record review of the Medication: Ordering, Administration, and Reconciliation facility policy revised and reviewed 07/09 in part revealed the following information:

III. Essential Steps in Procedure
6. Routine Drug Administration:
4. Right Time
a. Give drug within 1 hour before or after time noted.
6. Right Documentation
a. Document on MAR route time and initials at the time of administration.

Based on interview and record review the facility failed to ensure the policies and procedures governing medication administration followed accepted standards of practice and the facility failed to keep medications securely stored in two medication carts.

The facility policy and procedure for medication administration states medication can be given one hour before to one hour after the stated medication administration time. The facility administration was aware that the policy and procedure was inconsistent with accepted standards of practice. The census was 112. .
Findings included:
1. Record review on 08/11/10 at 11:00 a.m. of the facility policy MEDICATION: ORDERING, ADMINISTRATION, AND RECONCILIATION INDEX revised and reviewed 07/09 revealed, in part,
CHAPTER:
F. Administering Medications
4. Right Time
a. Give drug within 1 hour before or after time noted.
2. In an interview on 08/11/10 at 1:10 p.m. with Staff D, RN, Director, Performance Management & Clinical Outcomes, revealed administration is aware that the policy and procedure states medication administration is one hour before and one hour after the scheduled medication administration time. Staff D states administration has been doing studies to find a resolution and is aware that current practice and written nursing policy and procedures are conflicting.
3. In an interview on 08/12/10 at 11:00 a.m. with Staff V, RN Educator, Staff W, RN Educator and Staff X, RN, Director of Education stated they are aware of the conflicts with written nursing policy and procedure and the current accepted standard of practice and haven't yet decided how to handle it for the safety of their patients.



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4. An interview on 8/12/10 at 2:45 p.m. Pharmacy Director P stated he/she knew the facility policy on medication administration stated medication could be given one (1) hour before and after the ordered times.







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5. This surveyor observed a medication cart on 08/11/10 at approximately 8:30 a.m. in the hall nurses' station on the 4th floor which is a medical floor. Staff nurse "K" confirmed the medication cart will not lock and maintenance has been called about the problem. Staff nurse "K" stated that the hall nurses' station is staffed with one nurse and one aide (tech) and there are times when both the nurse and the tech would both be away from the hall nursing station at the same time. The nursing station is observed to have an open space between the hall and the medication cart making it possible for unauthorized persons to access medications in the medication cart. This area is across the hall from room 424. Employee "J" then instructed Employee "K" to move the unlocked medication cart to the locked medication room of the primary nurses' station on the 4th floor until the lock on the medication cart can be fixed.
The unlocked medication cart included the following medications:
Room 418-01, Patient #24: Bismatrol and Floranex;
Room 420-01, Patient #25: Aminophyridine;
Room 423-01, Patient #9: Isopto Tears and Nystatin Powder;
Room 424-01, Patient #23: Triamocinolone Acetonidne Cream, Alphagan, Nasal Moisturizing Spray and Xalatan;
Room 426-01, Patient #8: Monistat 7 Vaginal Cream and Hemorrhoidal Ointment;
Room 427-01, Patient #47: Sore Throat Spray.

6. This surveyor observed a medication cart on 08/11/10 at approximately 10:55 a.m. on the Cardiac Step Down Unit on the 3rd floor that was unlocked. The medication cart was in the hall unlocked and unattended. This made the medications available to anyone who walks down the hall. The medication cart included the following medications: Room 330-2, Patient #50, Nitrostat Bottle, Dok Plus; Room 340-01, Patient #48, Toprol-XL and Lisinopril; Room 341-01, Patient #49, Alcon Isopto Tears and Artificial Tear Ointment. The same medication cart also contained syringes and needles. The bottom drawer also contained a key in an open enveloped attached to the inside of the bottom drawer. The key opened the top drawer of the medication cart which has a separate locking mechanism from the rest of the medication cart. Observation of the top drawer revealed the top drawer was completely full of needles and syringes.

7. Interview with Employee "O" on 8/11/2010, at 10:50 a.m. revealed, the only reason a medication that has been checked out of the Pyxis (an electronic medication dispensing system) would be in the medication drawers of the medication cart would be if the medication was not given and if the medication was not given it should have been returned to the Pyxis.

-Employee "N" was present and could see the medication cart was not locked.

-Employee "J" was present when both medication carts were found to be unlocked and confirms the medication carts are unlocked, but should be locked. This employee explains the medication carts should self lock after 1.5 minutes of being accessed if the nurse fails to lock the medication cart. While inspecting the cart this surveyor timed the self locking mechanism of the medication cart and found the cart failed to lock even after waiting over 10 minutes. The cart finally self locked at 12 minutes after being accessed. This employee had the medication cart removed from the hall and taken to the nurses' station.

8. Interview with Pharmacist "P" on 08/11/10 at 11:10 a.m. regarding the findings of two medication carts not being locked: He was not aware there were two medication carts where the carts had faulty locking mechanisms. This employee stated he would have all of the medication carts in the hospital checked to make sure they are locking properly.