HospitalInspections.org

Based on medical record (MR) review, Facility PICC (Peripherally Inserted Central Catheter) Order Protocol review and staff interview, it was determined the facility failed to ensure their staff followed their protocol for assessment of the PICC for 2 of 3 patients reviewed who had a PICC. This affected MR #s 21 and 47 and had the potential to affect all patients with a PICC.

Findings include:
Facility PICC Order Protocol
Medicine 02-Peripherally Inserted Central Catheter (PICC) and Midline Placement Verification, Nursing Care, and Maintenance
1. Nursing Interventions:
a. Assess and document q (every) shift in Horizon Clinicals.
Arm circumference at access site in centimeters (cm)-- notify VAT (vascular assessment team) if measurement is > (greater) 2 cm from baseline of if unilateral swelling distal to PICC.
Length of catheter exposed (in cm) --Notify VAT if change from baseline.......

1. MR # 47 was admitted to the facility on 3/5/12 with diagnosis of a right hip fracture.

A physician's order was received 3/11/12 for the insertion of a PICC for Total Parenteral Nutrition (TPN). Review of the nursing note dated 3/11/12 revealed the PICC was inserted in the right arm with the total catheter length of 38 cm with no exposed catheter and base arm circumference of 29 cm. The PICC was discontinued on 3/23/12.

Review of the nursing notes 3/11/12 through 3/23/12 revealed no documentation of an assessment of the arm circumference or the length of the exposed catheter after the initial assessment on 3/11/12.

During an interview on 4/19/12 at 11:30 AM, Employee Identifier (EI) # 11, Vice President(VP)/Chief Nursing Officer (CNO), confirmed the nursing staff failed to follow the Facility PICC Order nursing intervention protocol.



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2. MR # 21 was admitted to the hospital on 4/1/12 with diagnoses to include Acute Mental Status Change and remained a current patient during this survey.

A PICC line was ordered on 4/3/12. The PICC line was inserted on 4/3/12 and measured 44 CM and the arm circumference was 37. There was no other documentation of the length of the PICC line nor the arm circumference in the medical record from 4/3/12 to 4/17/12.

EI# 1, the Director of Clinical Excellence, verified this information on 4/18/12 at 11:50 AM.

The nursing staff failed to follow the Facility PICC Order nursing intervention protocol.

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


Findings were:

Cross refer to Life Safety Code violations.

Based on review of the facility policies and procedures, review of medical records (MR's), observations, and interviews, it was determined the hospital failed to follow the facility policies and procedures for aseptic wound care techniques and ensure appropriate infection control practices were carried out at the offsite outpatient surgery center. This affected 2 of 8 patients (MR # 20 and MR # 15) requiring wound care and had the potential to affect all patients receiving services at the offsite Endoscopy center.

Findings Include:

Policy:
Clean Vs. (Verses) Sterile Dressing Techniques for Management of Chronic Wounds: A fact sheet
Originated By:
Wound Ostomy and Continence Nurses Society (WOCN) Wound Committee and the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) 2000 Guidelines Committee.
Updated/Revised WOCN Committee, 2011
... .....
Purpose:
To present an update on the status of information about clean verses sterile dressing technique to manage chronic wounds.
... .....
Definition of terms.
Sterile technique. .... Sterile technique involves strategies used in patient care to reduce exposure to microorganisms and maintain objects and areas as free from microorganisms as possible. Sterile technique involves meticulous hand washing, use of a sterile field, use of sterile gloves for application of a sterile dressing, and use of sterile instruments. " Sterile to sterile " rules involve the use of only sterile instruments and materials in dressing change procedures ...

Clean technique. Clean means free of dirt, marks, or stains (Rowley et al., 2010). Clean technique involves strategies used in patient care to reduce the overall number of microorganisms or to prevent or reduce the risk of transmission of microorganisms from one person to another or from one place to another. Clean technique involves meticulous hand washing, maintaining a clean environment by preparing a clean field, using clean gloves and sterile instruments, and preventing direct contamination of materials and supplies ... ....


1. MR # 20 was admitted to the hospital on 4/12/12 with diagnoses to include Right Hip Decubitus Ulcer.

On 4/17/12 at 10:00 AM the surveyor observed a dressing change to MR # 20's Left Hip. Employee Identifier (EI) # 18, the Registered Nurse, moved the garbage can with gloved hands then opened the Aquagel without changing gloves. MR # 20 had a bowel movement and EI # 18 cleaned the patient and did not change gloves before gathering the supplies needed for another wound care site. EI# 18 did not clean her hands or change gloves prior to touching the wound care supplies.




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2. MR # 15 was admitted to the facility 3/24/12 with a diagnosis of Unresponsive. The patient was on contact isolation and had multiple wounds which required daily assessments and wounds to the Ischial Tuberosity, Sacrum and the right foot and ankle which required daily wound care.

EI #19, the Wound Ostomy Nurse, was observed performing wound care to MR # 15's wounds to the ischial tuberosity and sacrum on 4/16/12 at 2:00 PM.

EI # 19 was gloved and in the process of performing the wound care. EI # 19 removed the soiled dressings from the sacrum and the ischial tuberosity wounds and cleansed both wounds. EI # 19 used a q-tip to apply a small amount of Santyl ointment to the wound bed of the ischial tuberosity. EI # 19 used the same q-tip, and the same process 2 additional times to apply the Santyl ointment to the wound bed. EI # 19 touched the tip of the Santyl ointment tube each time using the contaminated q-tip.

EI # 19 then took her gloved hands and pulled the curtain around and requested from a staff member a certain type gauze. She received the gauze from the staff member and continued the wound care using the same gloves. EI # 19 applied the dressings to the wounds and did not change her gloves or cleanse her hands until the wound care was completed.

An interview with the EI # 11, the Vice President(VP)/Chief Nursing Officer (CNO), on 4/16/12 at 3:00 PM confirmed the above findings.




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3. A tour of the offsite Endoscopy Center was conducted on 4/18/12 at 7:30 AM with EI # 3, the Vice President of Clinical Organizational Effectiveness. During the tour of exam room # 1 with EI # 17, the staff RN, and EI # 3, the surveyor observed a spiked bag of Intravenous (IV) fluids hanging on an IV pole beside the stretcher and another IV pole with a spiked bag of IV fluids located just inside the exam room door. The surveyor asked EI # 17, "Why do you have another bag of IV fluids hanging here?" EI # 17 replied, "I always go ahead and prepare another bag for my next case." The surveyor asked, "Do you have it hanging in the room while the procedure is going on?" EI # 17 replied, "Yes, is that a problem?" This bag of fluids had the potential of being contaminated during the procedure.

An interview with EI # 3 during the tour on 4/18/12 at 7:30 AM confirmed the above.

The Infection Prevention Manager, EI # 17, was interviewed on 4/19/12 at 10:20 AM, and verified the spiked IV fluids hanging in the exam room for the next case should not have been in the exam room during the procedure of another patient.