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Based on medical record review, document review and interview, the hospital failed to ensure nursing staff are providing ongoing patient monitoring, consistent with the patient's condition, including the timely notification to the provider of any pertinent findings or issues.

Findings include:

See Tags 0395 and 0405

Based on medical record review, document review and interview staff did not ensure Patient #1's condition was monitored with documentation of timely notification of findings to the provider in accordance with facility protocol and that skin care consults were obtained as ordered. This has the potential to result in a delay in treatment.

In addition, the nursing staff did not perform daily indwelling urinary catheter care for 3 of 12 patients and intravenous catheter care for 7 of 30 patients in accordance with facility policy. This has the potential for an increased risk for infection.

Findings include:

Review of the facility's Adult Protocol for Early Recognition and Management of Sepsis reveals septic or potentially septic patients are identified by hospital staff based on the following criteria: Suspected or documented infection plus any two of the following: Temperature <98.6 or >101.4, Heart Rate >90 beats per minute, Respiratory rate > 20 breaths, white blood cell count (WBC) <4 or > 12 or bandemia >10% or hyperglycemia > 140mg/dL in the absence of diabetes.The provider or appropriate response team is then notified, folllowing which the patient will be evaluated. If the provider feels the patient is septic, the adult sepsis protocol is initiated.

Review of hematology report dated 12/11/15 at 5:45am revealed a white blood cell count of 12.9.

Review of Physician Progress note dated 12/13/15 at 9:59am revealed leukocytosis-steriod induced. Monitor for fever.

Review of Physician Progress note dated 12/14/15 at 9:57am revealed the patient had a fever of 38.1C (100.5F) that morning. At 10:06am the physician's plan included obtaining cultures, lab work and bladder scan as the patient had not had the urge to void since the urinary catheter was discontinued earlier that day at 6:40am.

Review of Nursing Event Assessment notes revealed a Complete Blood Count report dated 12/14/15 at 11:15am with a WBC result of 33.7.

Review of vital signs dated 12/14/15 at 11:00am revealed temperature 99.0 F and heart rate 99. At 4:00pm temperature 101.8 F and heart rate 99.

Review of Nursing Event Assessment notes dated 12/14/15 revealed a SIRS (systemic inflammatory response syndrome) Alert was not called until 5:22pm with notification to the Physician Assistant despite the presence of an elevation in WBC, temperature and heart rate at 11:15am. In addition, five hours elapsed before a repeat temperature and heart rate was obtained at 4:00pm.

Interview with Staff G on 1/6/16 at 10:00am verified the above findings.

Review of Nursing Event Assessment of Sacrum for Patient #1 dated 12/18/15 at 8:00am indicates a sacral pressure ulcer was noted and a foam dressing was applied.

Review of Consult Orders dated 12/18/15 at 4:25pm and 12/24/15 at 9:37am revealed Wound Care referrals for the pressure ulcer. No evidence was found to indicate a wound care consultation was performed.

Interview on 01/7/16 at 2:30pm with Staff II and JJ confirmed these findings.



Review of policy "Urinary catheterization" last revised 5/13 indicates routine perineal care with soap and water to reduce meatal bacterial flora should be performed daily with inspection of urethra and surrounding tissue.

Review of the medical record for Patient #1 revealed a urinary catheter was inserted on 11/28/15. Documentation of daily indwelling catheter care was found on 12/10/15, 12/11/15, 12/13/15, and 12/20/15 only.

Review of medical records for Patient # 10 and 30 revealed both patient's had indwelling urinary catheters with no evidence of daily indwelling catheter care during the hospitalization.

Review of policy " IV Care and Maintenance- Adult/Pediatric " last revised 1/20/15 revealed intravenous(IV) sites are to be rotated and changed every 72 hours and as needed. Document time IV was discontinued including the condition of the site.

Review of the medical record for Patient #4 revealed an IV site was identified in the right wrist on 11/18/15 at 3:00pm. This was discontinued on 11/23/15 at 12:00pm. On 11/19/15 an IV site was identified in the left wrist, which was discontinued on 11/25/15 at 4:00pm. On 12/8/15 at 1:45pm an IV site was identified in the left hand. There is no documentation that the IV site had been discontinued. On 12/15/15 at 5:00pm an IV site was identified in the right forearm, which was discontinued on 12/19/15 at 12:00am.

Review of the medical record for Patient #7 revealed an IV site was identified in the right forearm on 1/3/16 at 7:00pm. The site was last assessed on 1/8/16 at 9:00pm with no documentation to indicate the site had been changed or discontinued.

Review of the medical record for Patient #9 revealed an IV site was identified in the left forearm on 12/29/15 at 3:00pm, which was discontinued on 1/6/16 at 9:00am. On 1/6/15 at 9:00am an IV site was again identified in the left forearm. The site was last assessed on 1/11/16 at 4:00am with no documentation to indicate that the IV site was discontinued.

Review of the medical record for Patient #13 revealed an IV site was identified in the left antecubital on 12/30/15 at 5:00pm. On 1/4/15 at 12:00am the site was discontinued. On 1/4/16 at 12:00am an IV site was identified in the left forearm. The site was last assessed on 1/10/16 with no documentation to indicate that the IV site was discontinued.

Review of the medical record for Patient #17 revealed an IV site was identified in the left antecubital on 12/28/15 at 9:00am. The site was last assessed on 12/30/15 with no documentation to indicate that the IV site had been discontinued.

Review of the medical record for Patient #19 revealed an IV site was identified in the left hand on 12/2/15 at 6:18pm. The site was discontinued on 12/6/15 at 8:12pm. On 12/7/15 at 12:00pm an IV site was identified in the left antecubital. The IV site was last assessed on 12/16/15 at 4:00pm with no further documentation to indicate that the site has been discontinued. On 12/12/15 at 8:00am an IV site was identified in the right forearm, which was accidentally removed on 12/20/15 at 11:00am.

Review of the medical record for Patient #30 revealed an IV site was identified in the right hand and left forearm on 12/17/15 at 8:00pm. There is no documentation to indicate these IV sites were discontinued. On 12/18/15 at 7:00pm an IV site was identified in the left antecubital with no documentation that the IV site was discontinued. On 12/19/15 at 5:40am an IV site was identified in the left wrist with no documentation that the IV site had been discontinued.

There is no evidence to indicate IV sites are being rotated and changed every 72 hours, nor is there documentation of IV discontinuation and site condition as required by facility policy.

Interview on 1/11/16 at 2:00pm with Staff G confirmed these findings.

Based on observation, interview and document review, the facility did not ensure the preparation and timely administration of medication in accordance with acceptable standards of practice. This has the potential to increase the risk of infection, as well as delay patient treatment.

Findings include:

Observation conducted on 01/05/16 at 10:30am of the 14th floor nursing unit revealed an open vial of multi-dose Humulin insulin in the medication refrigerator. Neither the date of opening or expiration was noted on the vial.

Interview with Staff J on 1/5/16 at 11:00am revealed that vials are to be labeled immediately upon opening with initial date opened and 28 day end use. It was further noted that multidose vials are taken into the patient room, the medication is drawn up and administered.

Review of the facility's policy " Multi-dose Medication Products " revised 07/06/15 indicates that upon first entry of a multi-dose vial, the date must be written on the vial along with a 28 day expiration date or the manufacturer's expiration date, if sooner.The policy does not address that multi-dose vials should not enter the immediate patient treatment area and that if brought in to the area, the vial must be dedicated for single patient use and discarded immediately after use in accordance with acceptable standards.

Interview on 01/05/16 at 1300 with Staff E verified this finding.

Review of the medical record for Patient #20 revealed that Vancomycin IV was ordered on 11/26/15 at 2:44pm. The medication was administered at 6:13pm, three and a half hours later.

Review of the Medication Administration Record for Patient #20 revealed the reason for late administration was noted to be " Med Not Available " .

Interview with Staff R on 01/07/16 at 1:30pm revealed the Vancomycin order for Patient #20 was received by pharmacy on 11/26/15 at 2:44pm, the order was reviewed at 2:51pm and delivered to the nursing unit at 3:00pm.

Based on medical record review, document review and interview the provider did not ensure the timely documentation of patient evaluation following a sepsis alert on Patient #1. This has the potential to negatively impact the continuity of patient care.

Findings include:

Review of the facility Protocol for Early Recognition and Management of Sepsis revealed if a potentially septic patient is identified by hospital staff, the provider or appropriate response team will be notified and the patient will be evaluated and the protocol implemented if the provider feels the patient is septic.

Review of the medical record for Patient #1 revealed that a sepsis alert was activated on 12/14/15 at 5:22pm and 9:18pm on 12/14/15 with physician documentation of patient evaluation dated 12/15/15 at 9:35am.

Interview on 01/06/16 at 1000 with Staff G confirmed these findings.