HospitalInspections.org

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Based on record review and staff interview, it was determined that the facility failed to ensure the complete investigation of a Complaint. This was evident in one (1) of one (1) Complaints reviewed (Patient #5).

Findings:

Review of a Complaint Form dated 07/10/14 documented a Complaint by a family member regarding "Pressure Ulcer treatment for the patient".

During an interview with Staff #24 on 09/08/14 at 1:00PM, the staff member stated that they received the following Complaint which stated "if appropriate care was provided, Patient #5 would not have progressed to requiring a colostomy".

The Complaint Form documented a conversation with the Physician and noted on 07/11/14 that "Wound Care assessed the patient and started treatment".

The facility could not provide documented evidence that the Complaint regarding Skin Integrity Management was investigated and that the complainant was advised of the outcome of the facility's investigation.

During an interview with Staff #9 on 09/08/14 at 1:30PM, the staff member agreed that there was no documented evidence that Patient #5's Complaint regarding Skin Integrity Management was investigated.
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Based on observations and staff interview, the facility failed to ensure that the patients' right to privacy was maintained. This includes the patients' presence and location in the facility. This was evident on one (1) of ten (10) Nursing Units toured.

Findings:

During a tour of 2 Central on 09/5/14 at 09:30AM, three (3) Telemetry Monitor Stations were observed positioned on the walls of the main hallway displaying the first and last names of twenty three (23) patients. These Monitors were in full view of anyone walking in the hallway.

During interview on 09/5/14 at 09:35AM, Staff #3 stated that all the Monitors displayed the patient's first and last names.

Staff #3 was present at the time of these findings.
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Based on record review and staff interview, the facility failed to ensure that the Quality Assurance (QA) Program assessed, analyzed, implemented and monitored appropriate corrective measures from the data collected from: a) the "Quality Assurance Pressure Ulcer Reports" and the Pressure Ulcer Incident Reports, and b) that Medication Error Incident Reports were correlated and trended house-wide to identify potential and actual problems so that appropriate corrective measures could be implemented and monitored.

Findings:

a) Review of the "Quality Assurance Pressure Ulcer Reports" from January 2014 - July 2014 and the "Facility Acquired Pressure Ulcer Documentation Results" from January 2014 - August 2014 revealed the following:

The "Quality Assurance Pressure Ulcer Reports" included a Section noted as "Goals" with columns for "Threshold", "Target" and "Outstanding" for the acquired (Nosocomial) Pressure Ulcers. Each of the columns documented "TBD" (To Be Determined).

Review of the "Facility Acquired Pressure Ulcer Documentation Results" documented that the monthly facility acquired unstageable/DTI (Deep Tissue Injury) numbers were:

January - Five (5)
February - Two (2)
March - One (1)
April - Five (5)
May - Five (5)
June - Three (3)
July - One (1)
August - Two (2)

The Report also indicated that the Units that had the highest number of facility acquired unstageable/DTI Pressure Ulcers for the last eight (8) months were:

CCU (Cardiac Care Unit) - Six (6)
4 North (Medical Surgical) - Six (6)
MICU (Medical Intensive Care Unit) - Four (4)
3 South (Medical Surgical) - Three (3)
Emergency Department - Two (2)
4 South (Telemetry) - Two (2)

There is no documented evidence that the Quality Assurance Program assessed, analyzed and included corrective measures to address the facility acquired Pressure Ulcers and/or the Units with the highest numbers of Pressure Ulcers.

During an interview with Staff #9 on 09/08/14 at 10:10AM the staff member stated for now they are collecting data. The staff member stated "We are tracking and trending data but not acting on it. The Incident Reports should have the follow-up. There is no overall review of the Pressure Ulcers because there is no goal number established. After September we will develop goals on the data. The goals were not set because we did not have enough data. When we have enough months of data, nine (9) months, we will set the goals".

Review of an Incident Report dated 05/16/14 revealed that Patient #5 had a DTI (Deep Tissue Injury) on his coccyx which was first documented in the 05/09/14 Medical Record. The follow-up documentation noted "staff aware of patient's condition. Treatment initiated and frequent repositioning continued".

The facility failed to provide documented evidence that the Incident was investigated.

During an interview with Staff #2 on 09/04/14 at 3:30PM, the staff member stated that any Hospital Acquired Pressure Ulcers Stage II and above get reported as an Incident. The Nurse Manager is responsible for the investigation.

A review of the Hospital Acquired Pressure Ulcer Incident Reports between 03/14 - 08/14 revealed the following:

Review of the Incident Report dated 03/02/14 for Patient #33 revealed that the patient developed a DTI to her right and left heels. The follow-up included to discuss this case at the Staff Meeting.

Review of the 4 South Unit Meeting dated 03/18/14 documented "in March a patient had developed Heel Ulcers bilaterally. One (1) of the Ulcers probably was present on admission as it presented as a necrotic Ulcer". However, no documentation was found prior to the necrosis being identified. Staff were reminded to "turn and position the patient every two (2) hours, heels must be elevated of the bed and a thorough assessment of patients must be done on admission and daily each shift".

The facility failed to provide documented evidence of an investigation.

During an interview with Staff Members #9 and #25 on 09/08/14 at 10:55AM, the staff members agreed that an investigation should have been documented.

Review of the Incident Report dated 04/09/14 for Patient #32 documented that the patient developed a DTI on the left heel. The follow-up included Nurse Education.

The facility failed to provide documented evidence of an investigation.

During an interview with Staff Members #9 and #25 on 09/08/14 at 10:55 AM, they agreed that a Plan of Correction is documented but "we don't know what went wrong" and an investigation should have been documented.

b) Review of the Medication Error Incident Reports between 03/14 - 08/14 revealed that the Incidents were individually investigated and included a Plan of Correction when needed.

The Medication Errors were not correlated and trended house-wide to identify potential and actual problems so that appropriate corrective measures could be implemented and monitored.

During an interview with Staff #9 on 09/08/14 at 1:40PM, the staff member stated that the Medication Error Incidents are not tracked and trended and put through Pharmacy Therapeutics. The staff member also stated this used to be a part of the Risk Management Report.
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Based on record review and interview, the facility failed to ensure a Registered Nurse supervised and evaluated the Nursing care of a patient in one (1) of seven (7) Emergency Department (ED) Medical Records reviewed (Patient #30).

Findings:

Patient #30 was admitted to the Emergency Department (ED) on 09/08/14 at 9:35AM by Ambulance for attempted suicide. The patient was cleared medically at 4:14PM and transferred to the ED Psych Access Unit at 6:30PM, pending evaluation from a Psychiatrist.

Review of the Medical Record on 09/09/14 at 9:45AM revealed the patient was assessed by the RN on the ED Psych Access Unit at 6:30 PM on 09/08/14 and the last Nursing Note was written at 6:45PM.

The Record lacked documentation that the patient was evaluated or observed again until 09/09/14 at 09:08AM, when vital signs were recorded. The Record lacked documented evidence that this patient with the diagnosis of attempted suicide was being monitored for more than fourteen (14) hours.

This finding was confirmed with Staff Members #14 and #15 at the time of Record review.
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Based on record review and staff interview, the facility failed to ensure that a Collaborative Care Plan (CCP) was developed to: a) address the care of patients with Pressure Ulcers in three (3) of ten (10) patients reviewed with Pressure Ulcers (Patients #5, #10 and #19), and b) to include specific interventions that are patient specific (Patients #8 and #9).

Findings:

a) Patient #5 is a fifty-four (54) year old male that was transferred from a Rehabilitation Center to the Emergency Department with chief complaints of slurred speech and dizziness. He had a past medical and surgical history of Congestive Heart Failure, Morbid Obesity (BMI: 53.5, height 5'8" and weight 352 pounds), Hypertension, Diabetes Mellitus, Chronic Kidney Disease, Bilateral Leg Edema with Venous Stasis Ulcers, Cervical Stenosis and Lap Band and Spinal Fusion Surgery. The patient had a differential diagnosis of TIA (Transient Ischemic Attack), Metabolic Disorder, Intracranial Bleed, CVA (Cerebral Vascular Accident) and Bradycardia and was admitted.

Review of the Admission Integumentary Assessment Report dated 05/05/14 at 4:01AM documented the patient's skin was intact except for Venous Ulcers on his right and left lower legs and that he was at risk for skin breakdown with a Braden score of 15.

On 05/09/14 at 4:07AM an unstageable/DTI (Deep Tissue Injury) Pressure Ulcer was identified on the sacrum with purple discoloration and measuring 4cm length by 3cm width.

On 05/16/14 at 1:03AM the Sacral Pressure Ulcer had purple black discoloration and measured 4cm length by 3cm width.

There is no documented evidence that the Physician and the Enterstomal Therapist were notified of the Pressure Ulcer until 05/16/14, seven (7) days after the Pressure Ulcer developed and became neurotic. The Nutritionist was notified 05/14/14, five (5) days after the Pressure Ulcer was identified.

During an interview with Staff #2 on 09/04/14 at 3:30PM the staff member confirmed the above findings. Staff #2 also stated on 05/09/14 when the DTI Sacral Pressure Ulcer was identified with purple discoloration and intact skin the Nurses should apply a barrier cream daily to the Pressure Ulcer and as needed. They do not need an Order from the Physician to do this.

Review of the Integumentary Assessment Reports between 05/09/14 and 05/16/14 with Staff #2 at that time revealed there was no documented evidence that barrier cream was applied to the Sacral Pressure Ulcer on 05/11/14 and 05/12/14.



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Patient #10 was admitted to the facility on 08/28/14 with diagnoses of Malignant Hypertension, Urinary Tract Infection and Altered Mental Status.

The Medical Record revealed the patient was admitted to the Surgical Intensive Care Unit (SICU) from the Emergency Department on 08/29/14.

Review on 09/05/14 of the Clinical Summary Section of the Electronic Medical Record revealed that the patient was admitted with a Stage II Pressure Ulcer to the Coccyx measuring 1cm x 1cm x 0.5cm.

A Collaborative Care Plan (CCP) was not developed for the patient's alteration in skin condition until 09/02/14, five (5) days after admission.

An interview was conducted with Staff #3 on 09/05/14 at approximately 10:15AM. The staff member stated that a CCP should have been developed when the Pressure Ulcer was identified on admission.

Staff #12 was present at the time of this finding.

Patient #19 was admitted to the facility on 07/10/14 with the diagnosis of Cellulitis of the Groin.

Review on 09/05/14 of the Clinical Summary in the Electronic Medical Record dated 08/31/14, documented a Stage II Pressure Ulcer to the left ear.

Review on 09/05/14 of the CCP dated 08/07/14 revealed that the Care Plan was not reviewed or revised to reflect the change in the patient's skin condition that was noted on 08/31/14.

An interview was conducted with Staff #11 on 09/05/14 at approximately 2:15PM. The staff member stated that the CCP should have been updated at the time the Pressure Ulcer was first noted on 08/31/14.

Staff #11 was present at the time of this finding.



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b) Patient #8 was admitted to the facility on 09/01/14 with diagnoses of Atrial Fibrillation and Pancytopenia. The patient was placed on "Protective Precautions" due to her compromised immune system.

Review of the Interdisciplinary Plan of Care on 09/04/14 lacked documented evidence that a Care Plan was initiated to address the patient's Pancytopenia.

An interview on 09/04/14 in the afternoon with Staff Members #6 and #7 confirmed this finding.

Patient #9 was admitted to the facility on 09/02/14 with diagnoses of Gastrointestinal Bleed and Anemia. The patient received a blood transfusion during her stay.

Review of the Interdisciplinary Plan of Care on 09/04/14 revealed that the bleeding Care Plan was initiated. The Plan of Care was not revised to address the patient's possible signs and symptoms related to a gastrointestinal bleed or the patient's Anemia.

An interview on 09/04/14 in the afternoon with Staff #8 confirmed this finding.
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Based on record review and interview, the facility failed to ensure that non-employee staff were educated on the Policies and Procedures of the facility for two (2) of three (3) Agency Personnel Records reviewed (Staff Members #16 and #17).

Findings:

Staff #17 is a Registered Nurse who has worked in Critical Care at the facility since 09/18/11.

Review of the Personnel File on 09/09/14 lacked documentation that orientation to the facility was provided for the Agency Staff upon employment.

Staff #16 is an Agency Surgical Technician who has worked in the facility Operating Room since 02/10/14.

Review of the Personnel File on 09/09/14 lacked documentation that orientation to the facility was provided for the Agency Staff upon employment

These findings were confirmed with Staff #18 at the time of review.
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Based on record review and interview, the facility failed to ensure that: a) a Physician's Order was obtained for medications, and b) that Orders were complete and the Nursing Staff clarified Medication Orders before administration. This was evident in two (2) of ten (10) Medical Records reviewed for patients with Pressure Ulcers (Patients #19 and #27).

Findings:

a) Review of the Medical Record for Patient #19 reflects that the patient is a seventy-seven (77) year old male who was admitted to the facility on 07/10/14 with diagnoses that include Cellulitis of the Groin.

Review of the Clinical Summary in the Electronic Medical Record for Patient #19 dated 08/31/14 documented a Stage II Pressure Ulcer to the left ear.

Review of the Physician's Order for Patient #19 revealed there was no Physician's Order obtained for the impairment in the patient's skin condition from the time the Pressure Ulcer was identified on 08/31/14 to the present, 09/05/14.

An interview was conducted with Staff #11 on 09/05/14 at approximately 2:20PM. The staff member stated that the patient was receiving Bacitracin Ointment for the Pressure Ulcer on the left ear but there was no Treatment Order. Additionally, Staff #11 stated that an Order should have been obtained at the time the Pressure Ulcer was identified.

Staff #11 acknowledged this finding.

b) Review of Patient #27's Medical Record on 09/08/14 in the afternoon, revealed the patient was admitted on 08/01/14 with the diagnosis of Bilateral Gangrenous Heels. The patient had a history of Diabetes and Peripheral Artery Disease.

A Podiatry Consult dated 08/05/14 documents instructions to "continue local wound care, Bactroban Cream and a dressing". Review of the Bactroban Medication Orders revealed the Order was written as "Mupirocin 2% Ointment (Bactroban) 1 application Topical every 12 (twelve) hours". No instructions as to where the Bactroban was to be applied was noted in the Order.

A review of the Medication Administration Record revealed the Bactroban was applied to the heels on 08/04/14, 08/05/14 and 08/06/14. The Bactroban was applied to the left forearm on 08/02/14, 08/07/14, 08/08/14 and a skin tear on 08/03/14 and 08/08/14. The application of the medication was inconsistent and was applied without clarification as to the area for application.

This was confirmed on 09/08/14 in the afternoon with Staff #1.
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Based on record review and staff interview, the facility failed to ensure that: a) documentation of implementation of the Physician's Order for Wound Care in five (5) of ten (10) Medical Records reviewed for patients with Pressure Ulcers (Patients #5, #15, #17, #18 and #31), and b) the Pressure Ulcer measurements were conducted as per facility Policy (Patient #5).

Findings:

a) Review of the Medical Record for Patient #5 documented that the patient was admitted on 05/05/14 with chief complaints of slurred speech and dizziness.

The Physician's Order Sheet dated 05/16/14 at 8:00AM documented an Order to cleanse the Sacral Pressure Ulcer "with wound cleanser, apply hydrophilic paste to maintain dime thickness, and may leave open to air or cover with secondary dressing PRN (as needed)".

Review of the Wound Care Interventions Sheets and Nursing Notes between 05/16/14 and 07/21/14 revealed that the following dates lacked documented evidence that the Wound Care Order was implemented: 05/17/14, 05/19/14, 05/21/14, 05/25/14, 05/31/14, 06/09/14, 06/13/14, 06/14/14, 06/18/14, 06/21/14, 06/25/14, 06/29/14, 06/30/14, 07/05/14, 07/16/14, 07/19/14, 07/20/14 and 07/21/14.

On 09/08/14 at 11:00AM Staff #1 confirmed this finding.

Patient #15 was admitted on 07/10/14. Wound Care Instructions from 07/31/14 - 09/08/14 revealed treatment as "Wound Care Site: Sacrum - Cleanse with wound cleanser, apply hydrophilic paste to maintain dime thickness, may leave open to air or cover with secondary dressing Qday (daily)".

Review of Patient #15's Medical Record on 09/05/14 lacked documentation for administration of the daily wound care to the Sacral Wound on 07/31/14, 08/01/14, 08/02/14, 08/03/14, 08/12/14, 08/13/14, 08/14/14, 08/18/14, 08/21/14, 08/23/14, 08/24/14, 08/25/14, 08/26/14, 08/27/14, 08/28/14, 08/29/14, 09/02/14, 09/03/14, 09/06/14, 09/07/14 and 09/08/14.

This was confirmed with Staff #13 at the time of review.

Patient #18 was admitted on 07/08/14 and developed a Stage I Pressure Ulcer on 07/30/14, which opened to a Stage III Pressure Ulcer on 08/27/14.

Wound Care Instructions from 07/31/14 - 09/08/14 revealed treatment as "Wound Care Site: Sacrum - Cleanse with wound cleanser, apply hydrophilic paste to maintain dime thickness, may leave open to air or cover with secondary dressing Qday".

Review of Patient #18's Medical Record on 09/05/14 lacked documentation for administration of daily wound care to a Sacral Wound on 08/02/14, 08/04/14, 08/14/14, 08/21/14, 08/24/14, 08/26/14, 08/27/14, 08/28/14, 08/31/14, 09/02/14, 09/05/14, 09/05/14, 09/07/14 and 09/08/14.

This was confirmed with Staff #10 at the time of review.

Similar findings were noted in the Medical Records for Patients #17 and #31.

b) Review of Patients #5's Admission Integumentary Assessment Report dated 05/05/14 at 4:01AM documented the patient's skin was intact except for Venous Ulcers on his right and left lower legs and that he was at risk for skin breakdown with a Braden score of 15.

On 05/09/14 at 4:07AM an unstageable/DTI (Deep Tissue Injury) Pressure Ulcer was identified on the sacrum with purple discoloration and measuring 4cm length by 3cm width.

Review of the Integumentary Assessment Reports between 05/27/14 and 06/15/14 revealed on 06/04/14 and 06/11/14 the weekly Sacral Pressure Ulcer measurements were not documented.

Review of the Policy titled "Wound Assessment, Prevention, Management and Documentation" dated 09/07/12, documented the measurement of the Pressure Ulcer will be documented weekly.

On 09/05/14 at 12:20PM Staff #2 confirmed this finding.
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Based on observation, staff interview and document review, the facility failed to ensure that medication and biologicals were labeled when opened with an expiration date according to facility Policy.

Findings:

An observational tour conducted with Staff #3 on Unit 2 Central at 9:30AM on 09/05/14, revealed one (1) open multi-dose vial of Humalog U-100 Insulin with no label indicating when it was opened or when it should be discarded.

Staff #3 acknowledge this finding.

Review of the facility Policy and Procedure titled "Use of Multi-Dose Vials" dated 03/2012 documented "Upon the first entry into a vial, the beyond use (expiration) date will be recorded on the vial's label or on an auxiliary label attached to the vial".
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Based on record review and staff interview, it was determined that the facility failed to ensure that: a) that Staff Education included documentation of competency in the use of the glucometer in four (4) of four (4) Personnel Files reviewed (Staff Members #20, #21, #22 and #23), b) Infection Control Practices were implemented during medication administration in three (3) of six (6) medication administration observations, and c) the Policy for Insertion and Management of Intravenous Catheters included Personal Protective Equipment instructions to prevent the spread of infection.

Findings:

a) Review of the Precision Xceed Pro Competency Quiz and Precision Xceed Pro Competency Checklist for four (4) of four (4) staff (Staff Members #20, #21, #22 and #23) revealed there was no documented evidence of competency for performing blood glucose monitoring.

An interview with Staff #19 on 09/05/14 at 9:45AM revealed that Nurses receive education during orientation and annually thereafter to perform blood glucose monitoring. There is no documented competency for this education. Staff #19 also confirmed the findings.



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b) A medication administration observation was conducted on 09/05/14 at 11:30AM. During administration of Ativan 2mg Intravenous Push (IVP) Staff #12 was observed not wearing gloves during the IVP administration of Ativan 2mg and after removing the cap from the Normal Saline (NS) flush syringe Staff #12 placed the open syringe on a magazine that was on the patient's over-bed table.

An interview was conducted with Staff #12 on 09/05/14 at 11:35AM. The staff member stated that they were in a rush to medicate the patient for her procedure.

Staff #3 was present during the observations and acknowledged the Infection Control issues.

During a medication administration observation on 09/04/14 at 2:00PM, Staff #4 was observed administering oral medications without washing their hands.

Staff # 3 was present during the observation and stated "Yes, I saw that too".

During a medication administration observation on 09/04/14 at 11:00AM, Staff #5 was observed accessing an IV without wearing gloves.

Review of the Policy titled "Intravenous (IV) Bolus Drug Administration" revealed on Page 4, under the Section titled "Procedure" Letter "D" Instructions "Wash hands and don gloves".

c) Review of the Policy titled "Intravenous (IV) Catheter, Intermittent Intravenous (Piggyback) Insertion and Management" revealed on Page 2 under the Section titled "Intravenous Catheter Insertion" Instruction #1 states to gather equipment including gloves.

Instruction #2 states "wash hands thoroughly" and #3-9 gives information on finding a vein and preparing the site. Instruction #10 states to "Insert the needle". No instructions are given to don gloves after hand washing prior to inserting the needle.

Review of Page 3 of the same Policy under the section titled "IV Additives" also reveals a lack of instructions to don gloves after hand washing before accessing the IV.
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Based on observation and staff interview, the facility failed to ensure the maintenance of a sanitary environment to control infections and communicable diseases of patients and personnel. This was evident on the tour of the 2 Central Unit.

Findings:

During a tour with Staff #3 on the 2 Central Unit on 09/05/14 at 9:30AM the following was observed:

The Clean Utility Room floor was visibly soiled with black spots.

The Dirty Utility floor was visibly soiled and sticky.

In the Nourishment Room, the door of the refrigerator was noted with brownish/yellow spots and was in need of cleaning. The rack in the collection tray of the ice machine was observed with a build-up of white matter and was also in need of cleaning.

The Unit hallway floor was soiled with black streaks.

Staff #3 was present and observed these findings.
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Based on record review and staff interview, the facility failed to ensure services were provided for the care of a patient in need of an Emergency Psychiatric Evaluation for one (1) of seven (7) Emergency Department (ED) Medical Records reviewed (Patient #30).

Findings:

Patient #30 was admitted to the Emergency Department on 09/08/14 at 9:35AM via Ambulance for attempted suicide. The patient was cleared medically at 4:14PM and the ED Physician ' s Note stated "Based on my evaluation, there is no contraindication to further evaluation by the Psychiatrist".

The patient was transferred to the ED Psych Access Unit on 09/08/14 at 6:30PM with evaluation from a Psychiatrist pending.

The Record lacked documented evidence that a Psychiatric Evaluation was ordered by the ED Physician. The patient was not seen by Psychiatry until 10:00AM on 09/09/14, nearly eighteen (18) hours after being medically cleared.

This was confirmed on 09/09/14 at 10:00AM with Staff Members #14 and #15.