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Based on interview, documentation in 3 of 4 medical records reviewed of patients with skin conditions (Patients 8, 9 and 11), review of policies, and procedures, and review of other documents, it was determined that the hospital failed to implement its policies and procedures to ensure that patient skin conditions were evaluated and monitored on an ongoing basis by an RN as indicated by the patient's condition. Patient skin conditions were not assessed and Braden scores were not completed in accordance with hospital policies and procedures.

Findings include:

1. a. A document titled "Pressure ulcer prevention" dated as revised "January 04, 2013" reflected "...Silicone Border Foam Dressing to prevent sacral and buttocks pressure ulcers...While using this type of dressing it is critical that skin assessments should still be done to assess tissue under the dressing, at least every shift, more if condition warrants."

The hospital policy and protocol titled "Skin/Wound Care Protocol" effective "July 2014" reflected "Skin/Wound Assessment...Complete a Braden skin risk assessment for each adult patient, on admission, transfer and every shift; and when there is a change in condition that may affect the Braden Score."

b. The record of Patient 9 reflected the patient was admitted to the hospital on 07/28/2014 with a diagnosis of cellulitis (a skin infection).

The nurse documentation on the "All Flowsheet Data" reflected a Braden score was completed on 07/31/2014 at 0746. The next Braden score was not recorded until 08/01/2014 at 0757, 24 hours later and 11 minutes later.

The nurse documentation on the "All Flowsheet Data" dated 08/05/2014 at 0922 reflected the patient had "blanching redness to coccyx."

The nurse documentation on the "All Flowsheet Data" dated 08/05/2014 at 2115 reflected "Patient has an Allevyn to bottom..."

The nurse documentation on the "All Flowsheet Data" dated 08/06/2014 at 1500 reflected the patient had a Stage 1 pressure ulcer (redness over a bony prominence).

The nurse documentation on the "All Flowsheet Data" reflected a Braden score was completed on 08/07/2014 at 2155. The next Braden score was not recorded until 08/08/2014 at 2134, 23 hours and 21 minutes later.

The nurse documentation on the "All Flowsheet Data" dated 08/07/2014, 08/08/2014 and 08/09/2014 reflected the patient's "Coccyx Stage 1" pressure ulcer assessment was "UTA" (unable to assess). The documentation further reflected that the patient had an Allevyn dressing on his/her coccyx. The patient was discharged on 08/09/2014 at 1449.

There were no documentation to reflect that the patient's coccyx was assessed between 08/06/2014 at 1500 and 08/09/2014 when the patient was discharged.

c. During an interview conducted on 10/01/2014 at 1040 a Clinical Nurse Specialist stated that for patients with a foam dressing such as Allevyn applied, the dressing should be lifted and the skin beneath the dressing assessed every shift.

2. a. The hospital policy and protocol titled "Skin/Wound Care Protocol" effective "November 2011" reflected "Skin/Wound Assessment & Documentation...Complete a Braden skin risk assessment for each adult patient, on admission and daily at a minimum..."

b. The record of Patient 11 reflected the patient was admitted to the hospital on 02/10/2014 at 0929 with severe sepsis and decubitus wounds.

The nurse documentation on the "All Flowsheet Data" reflected a Braden score was recorded on 02/22/2014 at 2300. The next Braden score was not completed until 02/24/2014 at 0837, 33 hours and 37 minutes later. The patient was discharged on 02/25/2014.

c. The record of Patient 8 reflected the patient was admitted to the hospital on 03/02/2014 at 1700 with a diagnosis of cholelithiasis (gallstones). The record reflected the patient had an allergy to tape, sensitive skin, and a history of skin breakdown.

The nurse documentation on the "All Flowsheet Data" reflected a Braden score was completed on 03/03/2014 at 2020. The next Braden score was not completed until 03/04/2014 at 2055, 24 hours and 35 minutes later. The patient was discharged on 03/05/2014.

d. These findings were verified during a review of the records with the Accreditation & Patient Safety Manager and Accreditation Specialist on 10/01/2014 at 0840.

Based on interview and documentation in 1 of 1 medical record reviewed of a patient admitted to the hospital with an allergy to tape and sensitive skin (Patient 8), it was determined that the hospital failed to ensure that a nursing plan of care was developed and kept current in relation to the patient's skin care needs. Interventions to address the patient's skin sensitivity and tape allergy were not addressed on the nursing plan of care.

Findings include:

1. The record of Patient 8 reflected the patient was admitted to the hospital on 03/02/2014 at 1700.

The PA notes dated 03/03/2014 at 0836 reflected "Admitted for recurrent pain/nausea associated with cholecystitis. Second admit in last week for same. Hx of proctocolectomy and ileostomy..."

A physician progress note dated 03/03/2014 at 0836 was reviewed. The top portion of the document had a list of allergies with corresponding "Noted" dates. "Tape" was on the list of allergies followed by "Patient has sensitive skin and tape can be a problem when torn off." The tape allergy had a "Noted" date of "5/16/2011."

The nurse notes dated 03/02/2014 at 2210 reflected the patient's skin was "Appropriate, even tone...Dry, Intact...WDL" (within defined limits).

The nurse notes dated 03/03/2014 at 0920 reflected the patient had blisters and skin tears to his/her left foot and "RUQ." This was the first documentation reflecting the patient's skin tears and blisters. There was no assessment of the cause of the skin tears and blisters or a nursing plan of care developed to address the skin condition.

The record reflected the patient underwent a gallbladder surgery on 03/03/2014. The physician operative report dated 03/03/2014 at 1543 reflected that the patient's surgical incision was dressed with gauze and tape.

The nurse notes dated 03/03/2014 at 1845 reflected "Pt has skin tears on abd above surgical dressing and lateral of surgical dressing..."

The PA notes dated 03/04/2014 at 0851 reflected the patient had skin breakdown wounds from tape. The patient was discharged on 03/05/2014.

The record lacked documentation reflecting the development of a nursing plan of care that addressed the patient's tape allergy and sensitive skin, including interventions for appropriate use of tape on the patient's skin to reduce the risk of tears and injury.

These findings were verified during an interview and review of the record conducted with the Manager of Accreditation & Patient Safety on 10/01/2014 at 0930.

Based on interviews, documentation in 1 of 3 medical records reviewed of a patient with confirmed TB (Patient 7), review of TST documentation for 1 of 2 medical staff (Employee 14), review of infection control policies and procedures, and review of other documents, it was determined that the hospital failed to develop and implement its policies and procedures to ensure control of patient and staff infections and/or communicable diseases. Appropriate isolation precautions were not implemented for patients in all cases; monitoring of airborne isolation rooms was not reported to the Infection Prevention department and/or staff; and TST of medical staff was not conducted in accordance with hospital policies and procedures.

Findings include:

1.a. The Infection Control policy and procedure titled "Isolation (Transmission-Based) Precautions" effective "March 2013" reflected "...an AIIR is a single-occupancy patient-care room used to isolate persons with a suspected or confirmed airborne infectious disease...use Airborne Precautions for patients known or suspected to be infected with micro-organisms transmitted from person-to-person by airborne droplet nuclei, (small particles that remain suspended in the air and can be dispersed widely by air currents within a room or over a long distance)...Special air handling and ventilation in Air-borne Infection Isolation Room (AIIR)...are required to prevent airborne transmission...Place the patient in a private AIIR, (negative pressure room)..."

b. The Infection Control policy and protocol titled "Tuberculosis" effective "December 2012" reflected "It is the policy of Salem Health for staff to follow protocols provided by the Hospitals to effect prevention of the transmission of tuberculosis...Initiate airborne precautions in the following:
A. Patients with pulmonary infections or conditions that present with signs and symptoms suggestive of tuberculosis...
B. Isolate patients with more general symptoms, which may be suggestive of tuberculosis, immediately, pending further diagnosis."

c. A list of hospital patients with confirmed TB for 2013 and 2014 was reviewed from which Patient 7 was selected.

The record of Patient 7 reflected the patient was admitted to the hospital on 07/04/2013 at 0839. The physician history and physical dated 07/04/2013 at 1316 reflected the patient's chief complaint was chest pain and headache; and the patient's diagnoses included probable pneumonia.

Physician notes dated 07/05/2013 at 0745 reflected the patient had "...Bilateral Infiltrates - possible pneumonia viral vs bacterial, in a patient with hx of bronchiectasis..."

The record reflected a physician order dated 07/05/2013 at 1500 for a "Culture - Acid Fast & Smear."

The physician notes dated 07/05/2013 at 1750 reflected "...The patient has the cough and sputum production for many years now...a year back, the patient had hemoptysis [coughing up blood], transiently...Has had a 10-pound weight loss over the past several months. No exposure to tuberculosis as far as [he/she] can remember. The patient has been treated with multiple antibiotics." The "Assessment and Plan" included "...bronchoscopy with bronchoalveolar lavage and send it for acid-fast bacilli..."

The physician discharge summary dated 07/06/3013 at 1257 reflected "...bronchoscopy was performed 7/5/13...Cultures pending at time of discharge..."

The record reflected the patient was discharged on 07/06/2013.

There was no documentation in the medical record reflecting that airborne isolation precautions were initiated at any time during the patient's hospitalization.

d. During an interview conducted on 10/02/2014 at 1220, the IC Manager stated the patient had suspected TB. The manager stated that the patient should have been placed in airborne isolation precautions when the physician ordered an acid fast bacilli culture on 07/05/2013. The manager stated that after the patient was discharged, the hospital received the patient's laboratory results from the culture which reflected that the patient had confirmed TB. The manager stated that the patient was not placed in airborne isolation precautions while at the hospital as he/she should have been. He/she further stated that the hospital did not conduct corrective actions after receiving the patient's confirmed TB results, in order to address the reason(s) the isolation precautions were not implemented.

2. a. The Infection Prevention policy and procedure titled "Negative Pressure Monitoring Guidelines" effective "October 2012" reflected "...The maintenance department will monitor all airborne isolation rooms monthly for negative air flow and functioning of the continuous monitoring equipment...A report of the monthly check will be sent to Infection Prevention for review purposes...When occupied by a patient in airborne precautions, the maintenance department will monitor any airborne isolation room without a functioning continuous monitoring device, daily, for negative pressure, and will send a report of the daily check to Infection Prevention for review...Any airborne isolation room, whose negative pressure cannot be reliably maintained as documented by the checks...will not be used for airborne isolation."

b. The Infection Prevention policy and procedure titled "Tuberculosis Exposure Control Plan," effective "January 2014" reflected "...Engineering Controls...Isolation rooms are designed to diminish the concentration of tuberculosis bacilli...The Engineering Department will monitor negative pressure daily, while the room is occupied by a patient with tuberculosis, and records in the Engineering Department and with a daily report by E-mail to the Infection Prevention Department...If unoccupied, the negative pressure rooms will be monitored monthly, and a record sent to the Infection Prevention Department."

c. During an interview conducted on 10/01/2014 at 1545, the Director of Facilities stated that there were times when negative pressure rooms were identified as not functioning properly and required corrective maintenance. He/she stated that reports of isolation room monitoring conducted by the facilities department were not sent to the Infection Prevention Department as reflected in hospital policies and procedures. The director stated that the policies needed to be updated because the process for monitoring the rooms had changed.

3. a. The Employee Health policy and procedure titled "Tuberculosis Screening for Privileged Providers," effective "December 2012" reflected "...Providers must have a PPD skin test performed per facility risk assessment...Test may be placed and read at provider's office or alternate workplace. In this case, provider must submit documentation of placement and reading...PPD tests may not be placed or read by provider themselves, or anyone else not trained in accordance with CDC guidelines...Attestations of receiving tuberculosis screening are not acceptable."

b. The Infection Prevention policy and procedure titled "Tuberculosis Exposure Control Plan" effective "January 2014" defined "Tuberculin Skin Test (TST)" as follows: "...a test for TB infection, using the Mantoux method, (0.1cc)...of purified protein derivitive, or PPD."

c. During an interview conducted on 10/01/2014 at 1230, the IC Manager stated the hospital's annual TB risk assessment reflected the hospital was "low risk."

d. Review of Email documentation dated 10/07/2014 at 1054 from the Accreditation & Safety Manager reflected that TB screening procedures for settings classified as low risk were as follows: "All HCWs should receive baseline TB screening upon hire, using two-step TST or a single BAMT to test for infection with M. tuberculosis...HCWs refer to all paid and unpaid persons working in health-care settings who have the potential for exposure to M. tuberculosis through air space shared with persons with infectious TB disease. Part time, temporary, contract, and full-time HCWs should be included in TB screening programs..."

e. Information received during review of personnel documents reflected that Employee 14, a contracted Physician, had a hire date of 04/21/2014 and resignation date of 07/31/2014.

f. An immunization form for Employee 14 was reviewed. The form was from another hospital and reflected "..PPD date: 7/31/13 Result: Negative (A copy of the test and results must be attached.)" The bottom of the document had an illegible signature and was dated "9/12/13."

It was not clear when the PPD skin test was administered versus when the result was read, or who interpreted the result. In addition there was no attached copy or any further documentation of the test or test results.

g. During an interview conducted on 10/01/2014 at 1430, the IC Manager acknowledged that the immunization form for Employee 14 lacked clear documentation to reflect when the PPD skin test was administered and when the result was read. The manager stated that Employee 14 should have had a 2-step PPD skin test. The manager acknowledged there was no documentation of a 2-step PPD skin test for Employee 14. He/she further acknowledged that hospital policies and procedures were not developed and implemented to reflect a 2-step PPD process for physicians.