HospitalInspections.org

Based on medical record reviews, review of facility policy and interviews with the facility staff, it was determined the medical record (MR) did not include information necessary to monitor the patient's condition in 4 of 4 patients with wounds (MR #3, MR #19, MR #20, and MR #21).

Findings include:

Facility Policy (reviewed March 2010)

Admissions
Procedure:
20. Complete full physical body assessment and indicate any areas of compromise etc., in skin condition. Mark any old scars, healing scars, tattoos etc. If any decubitus ulcers are identified upon admission please refer to the decubitus record and follow physician orders for wound care and/or implement standing protocols. (The decubitus record is a facility form to document the stage of the pressure ulcer-to include the date, the time, the site, the size, the depth, the color, the odor, the drainage, the treatment and who provided the treatment.)

1. MR #3 was admitted to the hospital on 8/3/10 with Dehydration, Hyperkalemia, Renal Failure and Decubiti.

Review of the medical record Admission Assessment Form revealed the patient had a decubitus ulcer. There was no documentation of the size of the decubitus except that it was a deep sacral decubitus with an odor. There was no documentation of the appearance of the ulcer. There was no Decubitus Record in the patient's medical record.

An interview with Employee Identifier (EI) #2, the Director of Nursing (DON) on 8/11/10 at 8:20 AM confirmed there were no measurements of the decubitus and no Decubitus Record in the medical record. EI #2 verified the decubitus should have been measured.


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2. MR #21 was admitted to the hospital 7/25/10 with diagnoses which included Urosepsis, Diabetes and Dementia.

Review of the medical record revealed the Admission Assessment Form dated 7/25/10 included documentation by the Registered Nurse(RN) of a Stage II decubitus on the patient's coccyx. There was no documentation of wound measurements or a description of the wound. The Physician's Order Sheet contained an order dated 7/26/10 for "Occlusive dressing to coccyx". Review of the daily nursing documentation for 7/26/10, 7/27/10, 7/28/10 and 7/29/10 revealed no assessment of the wound and no documentation of wound care.

In an interview on 8/12/10 at 12:25 P.M. EI#2 confirmed there was no documentation of wound care or an assessment.

3. MR #19 was admitted to the hospital 7/5/10 with diagnoses which included Cellulitis, Urinary Tract Infection and Decubitus Ulcer.

Review of the Decubitus Ulcer Record dated 7/5/10 revealed the decubitus measurement of "2x2". There were no units of measurement such as centimeters or inches.

Review of the Physician's Order Sheet revealed an order dated 7/6/10 to "Continue Decubitus care". There was no documentation of the wound care to be continued. There was no physician order for wound care until 7/7/10 when Duoderm was ordered.

An interview with EI # 2 on 8/12/10 at 12:35 P.M. confirmed the above.

4. MR # 20 was admitted to the hospital 7/21/10 with diagnosis Decubitus Ulcers.

Review of the Decubitus Ulcer Record dated 7/21/10 revealed an assessment of 16 decubitus ulcers; however, the measurements contained no unit of measurement.

An interview with EI # 2 on 8/12/10 at 12:30 P.M. confirmed the above.

Based on observations during a facility tour with hospital staff by the Life Safety surveyors and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.

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Based on policy review, observation, interview with Employee Identifier (EI) # 2 and # 6, and the U.S. Public Health Service Food Code the facility failed to:

1. Ensure food stored in walk-in refrigerator and reach-in refrigerator was dated and labeled.

2. Ensure solution for sanitation of pots and pans contained an acceptable concentration of sanitizer.

3. Assure single use items were used only as directed in the use of brush cleaners for cleaning diagnostic scopes. This had the potential to affect all patients who had colonoscopies.

Findings include:

U.S. Public Health Service Food Code 3-501.17
Ready to Eat, Potentially Hazardous Food
(B)...refrigerated, prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened...

U.S. Public Health Service Food Code 4-501.116
Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device.

During the initial tour of the dietary department on 08/10/10 at 9:30 A.M. the reach-in refrigerator had the following items with no date or label on containers: salad dressing, grated cheese, sliced cheese, chicken fingers, 10 plastic containers with unknown substances, and 2 pitchers of tea. The walk-in refrigerator also had containers of grated cheese and salad dressing that were not labeled. The Dietary Manager (EI#3) was present during the tour and stated, "I know these need to be labeled and dated."

On 8/11/10 at 1:00 P.M. the surveyor observed the cook, EI #4, cleaning pots and pans. Sanitizer was added to water used for rinsing. The employee did not check the level of sanitizer in the water. The surveyor asked,"How do you know if the sanitizer is working?" EI#4 replied, "It just works, it works in cold water."

An interview was conducted with the Dietary Manager(EI#3) on 8/11/10 at 2:30 P.M. EI#3 stated they have test strips for the sanitizer.


Manufacturer packaging information:

Disposable

Hospital Policy

Disposable Equipment, Reuse of

Policy

It is the policy of Lake Martin Community Hospital that all disposable, one time use items or equipment will not be resterilized.

Purpose

... Once opened on the sterile field, disposable or one time use items will be discarded at the end of the procedure.

1. The surveyor observed the technician, EI # 6, clean a colonoscope. The technician initially cleaned the exterior and interior with water prior to removing it from the procedure room. Then the technician took the scope across the hall to the cleaning room. The technician performed a leak test, placed the scope into a water solution and cleaned the scope using a brush and a syringe to clean both ports. The scope was then placed into a cidex solution for a 12 minute soak. The surveyor asked the technician what she does with the brush after cleaning the colonoscope? She replied, "we use it all day, then throw it away."

An interview with EI # 2, the Director of Nursing, on 8/12/10 at 10 A.M. revealed the scope cleaning brush is used on all scopes during the day, then thrown away.

A review of the brush packaging revealed it was a disposable one time use cleaning brush.