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Based on job descriptions reviews, observation, medical record review (Patient #11) and staff interviews, the facility staff failed to follow physicians orders by failing to document a bladder scan before performing an in and out catheter in 1 of 1 catheter insertion observations. (#11)

The findings include:

Review of the Registered Nurse job description with revision date of March 2019 revealed "Assesses, plans, implements, documents, organizes, prioritize, delegates, supervises and coordinates the care of ...adult, geriatric as prescribed within parameters of the NC Nurse Practice Act..."

Review of the Nursing Tech II job description with revision date of 02/19/2018 revealed "...Provides basic patient care...Provides patient care under the supervision of the Nurse, reporting observations, and documenting within the scope of practice into the EMR (electronic medical record). ..."

Observation on 08/06/2019 at 1310 revealed NT #1 performing a straight catheter on Patient #11. Observation revealed RN #1 was present in room during the straight catheter procedure.

Review of the medical record of Patient #11 revealed a 51 year old female admitted on 07/01/2019 with myelopathy due to spine metastasis from Thyroid cancer. Review of a physician order dated 07/24/2019 at 1621 for a Bladder scan "Once every 4-6 hours and cath for volumes 350 cc (cubic centimeters)." Review of NT #1's nursing documentation dated 08/06/2019 at 1339 revealed "Urine Color: yellow. Urine appearance: Clear. Urine Odor: No odor. Urinary Interventions: Intermittent/Straight Catheter. Intermittent/Straight Cath: 200 ml." Record review revealed no documentation of a bladder scan results prior to the catheter insertion.

Interview with NT #1 on 08/08/2019 was not obtained due to NT #1 was not available.

Interview with RN #1 on 08/08/2019 was not obtained due to RN #1 was not available.

Interview on 08/08/2019 at 1417 with RN #2 revealed nurses should follow physician's orders. Interview revealed RN #2 was charge nurse on most days. "The RN is responsible that physician's orders are followed." Interview revealed the physician's order for the straight cath is performed when the patient has not voided or the bladder scan reveals more than 350 cc.

Interview on 08/08/2019 at 0915 with Director of Quality revealed there is no documentation of the bladder scan prior to the straight catheter insertion. Interview confirmed the physician's order was not followed.

Based on review of policy, observation, review of medical records, the hospital failed to ensure infection control practices were followed by failing to wash hands before donning new sterile gloves during a catheter insertion in 1 of 1 catheter insertion observations. (#11).

The findings include:

Review of the "Skills--Urinary Catheter: Straight...Catheter Insertion.." (no revision date) revealed "Procedure: Catheter Insertion: 1.Perform hand hygiene and don gloves. 2. Verify the correct patient using two identifiers. 3. Explain the procedure to the patient and ensure that she agrees to the treatment....b. Washing minimizes contamination in the area before catheter insertion...9. Discard used supplies, remove gloves, and perform hand hygiene. 10. Obtain an indwelling catheterization kit or intermitten catheterization kit...."

Observation on 08/06/2019 at 1309 of NT #1 revealed a straight cath (one time catheter insertion to drain urine from the bladder) performed on Patient #11. Observation revealed NT #1 removed once sterile gloves after a catheter was contaminated during the first attempt of insertion. While waiting for replacement sterile gloves and a new catheter kit, NT #1 was observed wiping the corner of NT #1's eye with unwashed hands. After receiving new replacement sterile gloves and a catheter kit, NT #1 opened the sterile gloves without washing her hands.

Review of a medical record for Patient #11 revealed a 51 year old female admitted on 07/01/2019 with a diagnosis of spine metastasis due to thyroid cancer. Review of physician's orders dated 07/24/2019 at 1621 revealed "Bladder scan: Once every 4-6 hours and cath for volumes 350 cc (cubic centimeters--unit of measure).

Interview on 08/06/2019 at 1330 with NT #1 revealed "I should have washed my hands before putting on the new gloves. And should not have touched my face."

Interview on 08/08/2019 at 1145 with the Director of Infection Control revealed nurses should wash their hands before inserting a foley catheter. Interview revealed hand hygiene is best practice before performing patient care.

Interview on 08/06/2019 at 1340 with the Director of Rehab revealed hand hygiene should have been done before the catheter insertion. Interview revealed the policy for straight catheter insertion was not followed.

NC00152554; NC00152652