HospitalInspections.org

Based on record review and interview, it was determined the governing body failed to ensure:

1. The Primary Physician followed up in 1 of 1 records reviewed where the patient's albumin level was low and the nutritional consult requested a nutritional supplement.

Refer to A 049

2. The patients were cared for in a safe environment including staff wearing gloves, handwashing and clean equipment.

Refer to A 144

3. The Nursing staff:

A. Provided wound care as ordered

B. Provided an initial assessment of the patients with wounds

C. Provided an ongoing assessment of the patients with wounds.

D. Followed the Facility Policy for wound care.

E. Followed Drug Interaction Standards for wound care.

Refer to A 395

4. All infection control policies and standards were followed by the staff.

Refer to A 748


This affected 7 of 7 records reviewed with wounds Patient Identifer # 15, 23, 30, 31, 9, and 1 and had the potential to negatively affect all patients with wounds.

Based on record review and interview, it was determined the governing body failed to ensure the Primary Physician followed up in 1 of 1 records reviewed where the patient's albumin level was low and the nutritional consult requested a nutritional supplement. This negatively affected Patient Identifer (PI) # 1 and had the potential to negatively affect all patients served by this facility.

Findings include:

1. PI # 1 was admitted to the facility on 12/24/12 with diagnoses including Cholecystitis, Possible Common Bile Duct Obstruction, Ileus, Hypertension, and Back Pain.

Review of the laboratory results dated 12/25/12 at 4:48 AM revealed a albumin level of 2.30 (normal 3.5 to 5.00).

Review of the Nutritional Assessment dated 12/26/12 at 3:20 PM revealed recommendations by the Dietician as follows:
Dental Soft diet
Ensure TID (three times a day) as a nutritional supplement
Monitor weights, labs, intake and output
Continue multivitamin and Oscal D BID (twice a day).

Review of the progress notes dated 12/27/12 at 3:20 PM revealed documentation the Nutritional Services had Nutritional recommendations under the Dietary Tab.

Review of the Nutritional Assessment dated 12/31/12 at 2:00 PM revealed the following documentation by the Dietician :
No weight recorded, no D/U (Decubitus Ulcer) per flowsheet
Diet: Dental Soft with < 30% intake
Dietitian's Note recommended the following:
Continue Dental Soft diet
Assist in menu selection, tray set-up. Encourage intake of food and fluids.
Honor all food preferences per diet order.
Add Ensure TID with meals
Monitor weights, labs, intake and output
Add Oscal D BID.

Review of the progress notes dated 12/31/12 at 2:00 PM revealed documentation the Nutritional Services had Nutritional recommendations under the Dietary Tab. There were 14 entries per physicians in the progress notes between 12/27/12 and 12/31/12 Dietary entries.

Review of the Nutritional Assessment dated 1/5/13 at 5:35 PM revealed the following documentation by the Dietician :
No weight recorded, no D/U per flowsheet
Diet: Dental Soft with very poor intake reported by patient and no intake recorded. Patient request soup with lunch and dinner trays...
Dietitian's Note recommended the following:
Continue Dental Soft diet encourage intake
Assist in menu selection in AM, help with tray set-up. Encourage intake of food and fluids.
Honor all food preferences.
Add Ensure TID with meals
Monitor weights, labs, intake and output
Oscal D BID.

Review of the progress notes dated 1/5/13 at 5:35 PM revealed documentation the Nutritional Services had Nutritional recommendations under the Dietary Tab. There were 15 entries in the progress notes per physicians between 12/31/12 and 1/5/13 Dietary entries.

Review of the Nutritional Assessment dated 1/10/13 at 4:10 PM revealed the following documentation by the Dietician :
No weight recorded, no D/U per flowsheet
Diet: Mechanical Soft
Dietitian's Note recommended the following:
Continue diet encourage intake.
Patient may benefit from appetite stimulant
Check Prealbumin
Continue multivitamin
Monitor weights, labs, intake and output.

Review of the Vital Signs/I (intake) and O (output) Record between 12/24/12 and 1/14/13 revealed no documentation of the amount of meal consumption by the patient.

Review of the Physician Orders and Medication Administration Record revealed the following:

1. No documentation the physician ordered a dietary supplement three times a day with meals.

2. No documentation the physician ordered a weight check.

3. No documentation of an Albumin assessment after 12/25/12.

4. No documentation of an appetite stimulant until 1/13/13.

5. No documentation of an order to monitor the patient's meal consumption.

An interview was conducted with Employee Identifier (EI) # 1, Primary Physician on 1/16/13 at 7:40 AM. The surveyor asked EI # 1 if he/she was aware the Dietician made three different recommendations for Ensure 3 times a day and was there a reason the Ensure was not ordered? EI # 1 stated he/she was not aware of the ensure recommendation.

Review of PI # 1's medical record on 1/16/13 at 8:00 AM revealed an order from EI # 1 at 7:50 AM for Ensure or Boost three times a day.

The governing body failed to ensure the Primary Physician reviewed all recommendations made by the Nutritional Consultant.

Based on observations and interviews it was determined the facility failed to ensure the patients were cared for in a safe environment including staff wearing gloves, handwashing and clean equipment. This affected Patient Identifer (PI) # 3 and had the potential to negatively affect all patients served by this facility.

Findings include:

A tour of the Emergency Department (ED) was conducted on 1/16/13 at 1:30 PM. The surveyor reviewed the ED logs for 2013 and requested 10 medical records to be reviewed by the surveyor.

During observation of care provided on 1/16/13 from 1:30 PM to 3:00 PM the surveyor observed the following:

1. Employee Identifier (EI) # 8, ED Nurse was observed placing linen in the dirty linen container with an ungloved hand. EI # 8 then went back to the patient care area without hand hygiene.

2. EI # 8 then left the patient care area without hand hygiene and began documenting in the computer.

3. EI # 8 was observed obtaining blood via left antecubital space with a butterfly needle without gloves.

4. A step stool was observed in ED room # 101 with a reddish ring stain approximately 6 cm (centimeter) in diameter.

An interview was conducted with EI # 7, ED Director on 1/16/13 at 2:45 PM. EI # 7 stated recognition of 1 of 10 ED records requested by the surveyor. The surveyor asked which patient it was and the response was PI # 3. The surveyor then asked why he/she recognized PI # 3. EI # 7 stated that the Charge Nurse called on 1/7/13 to inform EI # 7 of a incidence with PI # 3. EI # 7 stated that PI # 3 sat on the stretcher and a few minutes later realized her cloths were wet from the previous patients urine. EI # 7 stated that the mattress was not cleaned underneath and the urine was from the previous patient.

Based on review of medical records, Potter - Perry Fundamentals of Nursing, facility policies and procedures, and drug interaction standards and interviews with administrative staff, it was determined the nursing staff failed to:

1. Provide wound care as ordered

2. Provide an initial assessment of the patients with wounds

3. Provide an ongoing assessment of the patients with wounds.

4. Follow the Facility Policy for wound care.

5. Follow Drug Interaction Standards for wound care.


This affected 2 of 2 records reviewed before 2/11/13 with wounds Patient Identifer # 1 and 2 and had the potential to negatively affect all patients with wounds.

Refer to A 395

Based on review of medical records, Potter - Perry Fundamentals of Nursing, facility policies and procedures, and interviews with staff, it was determined the nursing staff failed to:

1. Provide wound care as ordered

2. Provide an initial assessment of the patients with wounds

3. Provide an ongoing assessment of the patients with wounds.

4. Follow the Facility Policy for wound care.

5. Follow Drug Interaction Standards for wound care


This affected 2 of 2 records reviewed before 2/11/13 with wounds (Patient Identifer (PI) #s 1 and 2) and had the potential to negatively affect all patients with wounds.

Findings include:

Facility Policy: Assessment and Reassessment of Patients by Nursing Staff issued 4/5/10

1. Purpose: To establish guidelines for the admission assessment and reassessment of patients by the nursing staff to Medical West.

3. Standards:

3.1.2 The Admission Assessment is the responsibility of the registered nurse. The registered nurse will assess the patient upon admission.

3.1.4 The assessment data will be utilized in the development of the individualized nursing care plan.

3.1.5 The assessment may be accomplished through interview and observation of the patient, family and/or significant other and through review of other pertinent data such as; history and physical, x-ray reports, laboratory reports, previous admissions records and physician notes.

3.1.6 The admission assessment will include factors influencing nursing care or discharge planning, such as, a significant past medical history, age related factors, social history, presence or absence of pain, personal factors and a systems assessment.

4. PROCEDURE/CRITERION CHECKLIST:

Procedure Steps/Critical Elements: Admission assessment

1. COMPLETE ADMISSION ASSESSMENT AND HEALTH HISTORY...

Complete Skin Assessment

************
Policy Title: Assessment, Skin and Wounds, Written 7/6/06, Reviewed 3/5/10 and Revised 2/5/11.


Purpose: To establish guidelines for skin and wound assessment.
Standards:
3.6 Observation of dressing and/or wound shall be done...at least once per shift for length of hospital stay.
3.9 A Braden Skin Assessment shall be performed on admission and patients with a score of 16 or less will have high risk interventions implemented as directed in the Preventative Skin Care Guide.

**********
Braden Scale Protocol Interventions

Risk Factor 16 and below, Skin is broken HIGH RISK INTERVENTIONS

17. Order Wound Consult

18. All care should start ON admission. MEASURE ALL wounds, take photo and (place) in progress notes

************

Information from Drugs.com

Drug interactions between Grafco Silver Nitrate (Silvadene) and Santyl

Generally Avoid: The enzymatic activity of collagenase (santyl) may be adversely affected by heavy metal ions such as mercury and silver, which are found in some antiseptics. The mechanism of interaction has not been described.

Management: Topical preparations containing heavy metals such as silver and mercury should not be used on wounds treated with collagenase. When it is suspected such products have been used, the site should be carefully cleansed by repeated washings with normal saline before application of collagenase.

************

Facility Policy: Dressing Change Issued 4/5/10

1. Purpose: To establish guidelines for wound dressing changes.

2. Philosophy: It is our belief that proper wound dressing changes minimize the potential for infection and promote patient comfort and wound healing.

3. Standards:

3.5. Universal Precautions shall be followed during dressing change.

4. Procedure:

4.6. When doing multiple wound dressing changes, follow procedures and do each dressing change separately to prevent cross contamination.

4.7. Wash Hands

4.8. Put on non-sterile gloves.

4.10. Remove soiled dressing and place in plastic bag.

4.11. Remove soiled gloves.

4.12. Wash hands.

4.14. Apply gloves.

************

Facility Policy: Infection Control

OSHA (Occupational Safety and Health Administration) Bloodborne Pathogen Standard

Exposure Control Plan dated 7/30/08

Standard Precautions

1. Healthcare Personnel Hand-Washing

4. Decontaminate hands in the following situations:

h. After removing gloves...

III. Gloves:

B. Gloves must be worn:

1. When there is likelihood of hand contact with blood and any secretions or other potentially infectious materials.

2. During all vascular access procedures.

**********
Potter - Perry
Fundamentals of Nursing
6th Edition
Topical Medication Administration page 855

Skin Applications. Because many locally applied medications such as lotions, pastes, and ointments can create systemic and local effects, the nurse should apply these medications using gloves and applicators. ...Simply applying new medications over previously applied medications does little to prevent infection or offer therapeutic benefit. Before applying medications, the nurse cleanses the skin thoroughly ...

Potter - Perry
Fundamentals of Nursing
7th Edition
Chapter 48 Skin Integrity and Wound Care page 1311 - 1312

Cleansing: The process of cleansing a wound involves selecting both an appropriate cleansing solution and using a mechanical means of delivering that solution without causing injury to the healing wound tissue (WOCN, [Wound Ostomy and Continence Nurses Society] 2003).

Dressings: ...The correct dressing selection facilitates wound healing... The dressing type depends on the assessment of the wound and the phase of the wound healing. ...A wound that requires infection management requires a different set of dressing than a wound requiring the removal of nonviable tissue.

Types of Dressings. ...Pressure ulcers require dressings. The type of dressing is usually based on the stage of the pressure ulcer...



20228

1. PI # 1 was admitted to the facility on 12/24/12 with admitting diagnoses including Cholecystitis, Possible Common Bile Duct Obstruction, Ileus, Hypertension, and Back Pain.

Review of the Present on Admission Assessment from the Emergency Department dated 12/24/12 at 1:00 PM revealed documentation of a pressure ulcer to the right and left heel. There was no documentation of a measurement, description or photo.

Review of the RN (Registered Nurse) Physical Assessment and History Data dated 12/24/12 at 3:16 PM revealed the following documentation:

No edema, rash, bruises/hematoma, abrasions, lacerations, or fungus

Other Skin Ulcers/lesions (not due to pressure) N (no)

Pressure Ulcer Present on Admission N

Does patient have an open draining wound N

Review of the Plan for Nursing Care: Medical/Surgical Patient revealed no documentation for a goal or intervention under alteration in Healing related to wounds.

Review of the twenty one 24 Hour Flow Sheets dated between 12/24/12 and 1/13/13 revealed no documentation of a dressing change/location, drainage amount & color, or wound appearance for the wounds to the left and right heel.

There was no documentation in the medical record of the patient's pressure ulcers to the left or right heel until 1/12/13 at 12 noon when the daughter asked about the condition of the patient's left heel due to complaints of pain.

Review of the Physician's Order dated 1/12/13 at 5:10 PM revealed an order for General Surgery Consult concerning left foot pain (area on heel).

Review of the Physician's Order dated 1/13/13 at 6:50 AM revealed orders for an I & D (incision and drain) of left heel, removal of the left great toe nail and an I&D 2nd toe nail to be completed 1/14/13.

Review of the Consultation Report dated 1/13/13 revealed patient had been complaining the left heel was sore and found to have a left heel decubitus.

Review of the Operative Note dated 1/15/13 ( which should have been dated 1/14/13) revealed documentation as follows, "...we debrided the heel all the way down to the bone and bleeding tissue...It was a eschar with some wet and dry gangrene noted. We excised it all the way down to the bone...then the second toe on the right foot had what looked like an infection area over the top of the toe. I was able to debride it all the way down to the bleeding tissue..."

Review of the Nurse Note dated 1/14/13 revealed the patient was off the floor to surgery at 9:00 AM and returned to the floor at 4:00 PM.

Review of the Nurse Notes dated 1/15/13 at 9:00 AM revealed the nurse changed the dressing to the left heel.

The medical record was reviewed by the surveyor on 1/15/13 at 10:00 AM. There was no documentation of a decubitus to the left heel until 1/12/13 when the patient began complaining of pain to the left heel. There was no documentation of the left heel wound size, appearance or condition of the surrounding tissue.

In an interview with Employee Identifier ( EI) # 2, Chief Nursing Officer on 1/15/13 at 10:40 AM, when the surveyor asked for wound measurements, photo, and description. EI # 2 was unable to locate any documentation of the wound description of any kind. EI # 2 stated there should have been photos on admission, measurements, descriptions of the wound and surrounding tissue.

On 1/16/13 at 7:50 AM the surveyor reviewed the medical record and there was no documentation of wound measurements, a photo, or a description.

The surveyor then requested to see the wound. EI # 2, Chief Nursing Officer and EI # 3 , Registered Nurse went to PI # 1 room with gauze and normal saline (NS). EI # 2 removed the dressing from the left heel. There was approximately a 5 cm (centimeter) ring of dried blood on the old dressing. EI # 2 threw the dressing in the regular trash. EI # 2 measured the wound 5 cm long, 4 cm wide, and 1/2 cm deep with blood red tissue. Bone was exposed.

EI # 2 cleansed the wound to the left heel with the same pair of gloves used to remove the old dressing, using NS and gauze. EI # 2 then covered the wound with gauze moistened with NS, removed the gloves and EI # 3 then wrapped the wound. EI # 3 then removed the dressing from the left great toe and was waiting for EI # 3 to return with more gauze. The left great toe was dripping blood on to the linen. EI # 3 placed gauze under the toe to catch the dripping blood. After EI # 3 dressed the left great toe EI # 3 threw the gauze the toe had been dripping on in the regular trash.

EI # 3 then removed the dressing from the right 2nd toe with the same pair of gloves used to remove the dressing from the left greater toe. EI # 3 then dressed the left greater toe and the right 2nd toe with the same gloves.

An interview was conducted with EI # 2 on 1/15/13 at 11:00 AM. The surveyor asked if the PI # 1 received a consult with a wound nurse. EI # 2 stated they did not have a wound nurse at present but did use a Nurse Manager as a resource if needed. The surveyor asked if the resource person had seen PI # 1 and the response was no.

2. PI # 2 was admitted to the facility on 12/26/12 with diagnoses including Cancer of the Lung and Wounds to Bilateral Feet.

Review of the Physician's order dated 12/26/12 at 9:00 AM revealed orders for the nurse to remove dressings on lower extremities (LE) and assess and wash the wounds. Wash the lower extremities daily apply Bactroban cream, nonocclusive dressing and wrap.

Review of the Medication Administration Record (MAR) and the Nurse Note dated 12/26/12 revealed no documentation the nurse washed the LE, applied Bactroban cream, nonocclusive dressing and wrapped.

Review of the Physician's Order dated 12/28/12 at 7:15 AM revealed orders for the staff to treat both foot wounds daily with Santyl - apply a layer "nickle - thick" and wet to dry dressing on top of both - then wrap feet with kerlix.

Review of the physician's order dated 12/29/12 at 4:45 PM revealed orders for silvadene dressings to both foot wounds now and daily.

Review of the MAR and the Nurse Note dated 12/29/12 revealed no documentation the staff applied silvadene to both wounds on the feet.

Review of the MARs dated 12/30/12, 12/31/12, 1/1/13, and 1/2/13 revealed documentation the nurses applied both santyl and silvadene.

Review of the physician's order dated 1/3/13 at 1:00 PM revealed orders for the following dressing changes. Apply Santyl to both foot wounds daily with wet to dry dressings and Kerlix wrap.

Review of the MARs dated 1/3/13, 1/4/13, 1/5/13, 1/6/13, 1/7/13, 1/8/13, 1/9/13, 1/10/13, 1/11/12, 1/12/13, 1/13/13, 1/14/13, and 1/15/13 revealed documentation the nurses applied both santyl and silvadene.

An interview was conducted with EI # 4, Pharmacist on 1/13/13 at 11:35 AM. The surveyor asked why the staff continued to apply Santyl and Silvadene, did one not counter act the other. The response was the pharmacy staff were not told to stop one wound care to begin another.

An interview was conducted with EI # 6, Surgeon on 1/16/13 at 12:30 PM. The surveyor asked if EI # 6 expected the staff to stop using one wound care order before starting another. EI # 6 stated, "Yes I would. They did didn't they?" The surveyor told EI # 6 that the staff were using both Santyl and Silvadene at the same time. EI # 6 stated, "Oh no."

Based on a review of medical records and interview with staff, it was determined the facility failed to update or revise the nursing care plan with up to date information from ongoing patients' assessments. This had the potential to affect all patients served by the facility and did affect Patient Identifiers (PI) #s 11, 7, 21, 22, 9 and 15, which was 6 of 24 records reviewed.

Findings include:

Facility Policy: Plan of Care
Issued: 2/4/13

4. Standards: ...

4.3 The plan will be reviewed daily and revised in response to patient care needs and expected outcomes.

4.4 The Plan of Care will communicate information about the needs/problems of the patient and guide the health care team in the provision of nursing care.

4.5 The Care Plan will: ...

4.5.2 Include the medical plan of care

4.5.3 Be consistent with ancillary departments therapies

4.5.4 Be readily available to the health care team

4.5.5 Be used in patient care conferences, discharge planning meetings and change of shift reports...

4.6.6 Being congruent with the therapy prescribed by the physician...

4.7 The Plan of Care will include the specific patient needs, goals nursing orders that will promote and maintain the patient's maximum potential by:

4.7.2 Identifying and documenting patient problems and required nursing interventions, on the nursing care plan.

4.7.3 Formulating patient goals that are realistic, measurable and mutually developed with the patient, family and/ or significant other when possible...

4.9 Utilization of the Plan of care and the patient's response to the care given will be recorded in the patient's medical record by:

4.9.1 Documenting implementation of medical therapy and nursing interventions.

4.9.2 Documenting the patient's response to care received.

4.9.3 Documenting the evaluation of goals and nursing interventions.

4.10 Review of the care plan shall be completed daily

4.10.1 Care plans are updated with the 24 hour flow sheet...

4.10.2 To indicate review of the Care Plan by RN (Registered Nurse) when no revisions are indicated write in care plan section "Reviewed continue care plan of" and the date.


1. PI # 11 was admitted to the facility 2/8/13 with abdominal pain. On 2/10/13 the patient underwent surgery for a Cholecystectomy and Hernia Repair.

The plan of care established 2/8/13 was as follows:

Patient Problem/Diagnosis: "Alteration in Comfort r/t (related to) Abdominal Pain"

Goal: "Patient will verbalize acceptable level of comfort"

Planned Nursing Interventions:
Assess for discomfort using pain scale q (every)_____ and document;
Administer pain medication per MD (Medical Doctor) orders,
Reassess for effectiveness of pain medication and document,
Consult with MD if ordered medications are not effective

The Nursing Care Plan was reviewed 2/9/13 and 2/11/13 with no additional patient problems/diagnoses identified.

An interview with EI # 2, Chief Nursing Officer (CNO) on 2/13/12 at 1:45 PM confirmed the Nursing Care Plans were not updated and patient specific.




18155

2. PI # 7 was admitted to the facility on 1/23/13 with a diagnosis of Abnormal Coagulation and Coumadin Toxicity.

There was one undated photo of the wound to the left hand in the medical record. The photo included a small measurement instrument held up to the left hand wound and it indicated the wound was 2 cm. in length. There was no width or depth measured.

The Care Plan dated 1/23/13 contained documentation there was "No break in Skin". The nurse did not include the break in skin in PI # 4's Care Plan.


EI # 2, was interviewed on 2/13/13 at 1:42 PM who verified the Care Plan did not contain documentation the patient had a wound.

The "Patient Intervention Activity Sheet" dated 1/23/13 contained documentation PI # 4 had a "Bruise ... Abrasion" to left hand.

The "Patient Assessment" dated 1/23/13 at 8:00 PM, contained documentation, "Changed dressing and secure with tape." The documentation did not indicate where the wound was located, what the wound was cleaned with prior to applying a dressing, what type of dressing was applied, or measurements/ description of the wound. There was no physician order for wound care to the left hand found in the medical record.

The "Patient Assessment" dated 1/24/13 at 4:20 AM, contained documentation, "Changed dressing to LT (left) hand." The documentation did not indicate where the wound was located, what the wound was cleaned with prior to applying a dressing, what type of dressing was applied, or measurements/ description of the wound.

EI # 2, was interviewed on 2/13/13 at 1:42 PM who verified the Care Plan did not contain documentation the patient had a wound.

3. PI # 21 was admitted to the facility Geri-Psych Unit on 2/10/13 with a diagnosis of Bipolar Disorder and Major Depression.

The "Psychosocial Report" dated 2/12/13 identified, "When asked how he spends his free time, he says he spends his free time reading, praying, golfing, and building puzzles."

The Unit Schedule was posted in the Activity/Dining area:

9-11:30 OT (Occupational Therapy)
12- 1 Lunch
1-2 Visitation
2- 3:30 SW (Social Worker) Group/ Chaplain
3:30 - 4 Patient Education Group
4:30 - 5:30 Supper
5:30 - 6:30 Visitation
7 - 8 Relaxation Group

During an observation on 2/11/13 at 11:15 AM, PI # 21 was watching TV with another male patient.

PI # 21 was observed again on 2/11/13 lying in the bed at 2:00 PM.

During an observation on 2/11/13 at 2:35 PM, EI # 27, Geri- Psych Unit Secretary, was asked where the Social Worker was located. EI # 27 stated the Social Worker was gone to lunch and would be back. The SW was at lunch during the scheduled SW/ Chaplain group scheduled for 2:00 - 3:30 PM. There was no group meeting in the activity/dining area. The patients were observed walking in hallway, watching TV, or in their rooms.

The OT, EI # 26, was observed leading a group on 2/12/13 at 10:00 AM. There were 6 patients in the group with 3 patients resting with eyes closed. EI # 26 attempted to engage each patient by calling the patient by name but with little response. The group ended at 10:20 AM. PI # 21 was a part of the group but did not interact with EI # 26 or other patients.

The Geri-Psych Unit Director, EI # 11, on 2/13/13 at 9:47 AM informed the surveyor OT saw patients in the main hospital also and should be on unit soon.

During an observation on 2/13/13 at 10:00 AM the OT Group started.

EI # 26 did not arrive to the unit until 10:00 AM both days of observation. The group was to begin at 9:00 AM.

PI # 21 was interviewed on 2/13/13 at 10:30 AM. PI # 21 stated he was bored most of the time. He was asked what type of activities had the staff offered and he stated the staff had not offered anything but the TV and to rest in his room. He also stated, "I don't have much in common with the other patients. " The surveyor asked if the staff had offered puzzles, books or anything else he might be interested in and he stated, "No."

The staff did not adhere to the stated schedule of OT from 9:00 - 11:30. The staff also did not Care Plan individualized activities for PI # 21.

The Care Plan for PI # 21 was initiated on 2/10/13. One of the Goals was "Pt will verbalize knowledge and acceptance of the need for continued therapy, chemotherapy, regular blood test, and so forth." PI # 21 was not taking chemotherapy. The interventions listed for this goal did not include what blood test would be scheduled and what type of chemotherapy PI # 21 needed knowledge of and how to achieve acceptance.

Another Goal listed on the 2/10/13 Care Plan "Mental Status: is maintained at pt's maximum attainable level of functioning". The Interventions listed were:

Communication- Provide Alternative
Use yes/no questions
Use simple words, short sentences
Utilize eye blink
Utilize lip reading
Utilize sign language
Utilize pen/paper
Provide picture board
Communication by gesture

These interventions were listed for a patient who could easily communicate with words and complex ideas. These interventions were not appropriate for PI # 21.

4. PI # 22 was admitted to the facility Geri-Psych Unit on 2/6/13 with a diagnosis of rule out Delirium and Psychotic Disorder.

During an observation on 2/11/13 at 10:15 AM revealed PI # 22 had a vest restraint and was in a Gerichair with the foot rest raised.

During an interview with EI # 11, Unit Director, on 2/11/13 at 11:02 stated PI # 22 had fallen at home and had a black eye and a small cut to forehead from the fall at home.

A review of the Care Plan Dated 2/6/13 revealed there was no documentation PI # 22 had a vest restraint or Gerichair for PI # 22's protection form Falls.

5. PI # 9 was admitted to the Geri- Psych unit on 2/5/13 with a diagnosis of Dementia.

A "Physician's Order" dated 2/5/13 at 7:40 PM, contained documentation, " Continue wound care- Vaseline gauze dressing- Bactroban cream to area PRN (when needed)." This order did not specify PI # 6 had two wounds, where the wounds were located, what type of cleansing agent to use, or what type of dressing to apply over the Vaseline gauze to cover the 2 burn wounds.

The Care Plan dated 2/6/13 had a problem identified as "Skin Integrity Alteration R/T (related to) Pt (patient) has a burn to Left Arm." This did not identify PI # 9 had two wounds to the left forearm. The intervention for this problem was "Wound Care: Dressing Change daily. Assess wound daily for any s/s (signs and symptoms) of infection. Assessment: Shift." There was no documentation in the medical record PI # 9 had two wounds to the left forearm, a daily wound description, or measurements of the two wounds.


32470



5. PI # 15 was admitted to the facility on 2/8/13 with diagnoses of UTI(Urinary Track Infection), Positive Escherichia Coli Infection and a wound to the Left Ankle.

Review of the RN (Registered Nurse) assessment dated 2/8/13 at 4:41 PM revealed the patient had a draining wound to the "left lateral leg at ankle".

Further review of the medical record revealed the patient pain was "4" on a scale of 0-10 with 0 being no pain and 10 severe pain.


The nurses documented on 2/8/13 at 7:06 PM the patient had 2 to 3 plus edema to the lower extremities and the patient reported "numbness in the lower extremities".


On 2/12/13 the surveyor observed EI # 15, Registered Nurse (RN), perform wound care. Upon entering patients room the patient stated "I'm in pain but I guess I can wait until you finished my dressing change."


The Plan for Nursing Care dated 2/8/12 revealed the following: "Alteration in skin integrity related to wound left lateral leg."


The Plan of Nursing Care was not updated or initiated for Alteration in comfort, or Risk for fall.


An interview with EI # 2 on 2/13/12 at 1:40 PM confirmed the Plan for Nursing Care was not initiated specific to all the patients problems/needs and updated timely.

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:

Refer to the Life Safety Code survey report for findings.

Based on observations and interviews it was determined the infection control officer failed to ensure all infection control policies and standards were followed by the staff. This affected Patient Identifer # 1, 3, 9, 15, 23, 28, 30 and 31 and had the potential to negatively affect all patients served by this facility.



Refer to A 748

Based on observations and interviews it was determined the infection control officer failed to ensure all infection control policies and standards were followed by the staff. This affected Patient Identifer (PI) # 15, 23, 30, 31, 9 and 1 and had the potential to negatively affect all patients served by this facility.

Findings Include:


Facility Policy: Dressing Change Issued 4/5/10

1. Purpose: To establish guidelines for wound dressing changes.

2. Philosophy: It is our belief that proper wound dressing changes minimize the potential for infection and promote patient comfort and wound healing.

3. Standards:

3.1. Dressing changes shall be initiated by physician's orders.

3.1.1. Dressing change procedure shall be followed when order is written for "Dressing Change" unless otherwise specified by M.D. in order.

3.4. Wounds will be assessed during dressing change for signs of healing and/or complications such as odor, redness, swelling, color and type of any drainage and approximation of wound edges.

3.4.2. Description of wound shall be documented in the patient's medical record.

3.5. Universal Precautions shall be followed during dressing change.

4. Procedure:

4.6. When doing multiple wound dressing changes, follow procedures and do each dressing change separately to prevent cross contamination.

4.7. Wash Hands

4.8. Put on non-sterile gloves.

4.10. Remove soiled dressing and place in plastic bag.

4.11. Remove soiled gloves.

4.12. Wash hands.

4.14. Apply gloves.

************

Policy: Hand - Washing and Standard Precautions Issued 7/11/05

Philosophy: It is our belief that using Standard Precautions on all patients receiving care in the hospital will reduce the risk of hospital-acquired infections.

Procedures:

5.1 Hand Hygiene

5.1.3. Indications for Hand washing and Hand Antisepsis shall include:
5.1.3.1. Before having direct contact with patients.
5.1.3.2. Before donning gloves and performing an invasive procedure.
5.1.3.3. After removing gloves or other personal protective equipment.
.........

5.1.5. Hand washing Procedure with Liquid or Foam Soap:

5.1.5.6. Use paper towel to turn off faucet.

************

Centers for Disease Control (CDC) Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings

What Type of PPE Would You Wear?

Drawing blood from a vein? Gloves

************
CDC Guidelines for Bloodborne Pathogens
by Beth Celli, eHow Contributor

Bloodborne Pathogens

Bloodborne pathogens are microscopic organisms (or microorganisms) that can cause illness in people. They are found in the blood or other body fluids. Human immunodeficiency virus (HIV) which causes AIDS, and hepatitis B virus (HBV), are two of the most common bloodborne pathogens. These diseases and others pose a serious threat to health care workers.

Management of Waste

All materials that are contaminated with blood or body fluids should be disposed of in a red bag, or biohazard trash...

************
Facility Policy: Infection Control

OSHA (Occupational Safety and Health Administration) Bloodborne Pathogen Standard

Exposure Control Plan dated 7/30/08

Standard Precautions

1. Healthcare Personnel Hand-Washing

4. Decontaminate hands in the following situations:

h. After removing gloves...

III. Gloves:

B. Gloves must be worn:

1. When there is likelihood of hand contact with blood and any secretions or other potentially infectious materials.

2. During all vascular access procedures.


PI Findings Include:

1. PI # 15 was admitted to the facility on 2/8/13 with diagnoses of UTI(Urinary Track Infection), Positive Escherichia Coli Infection and a wound to the Left Ankle.

An observation of wound care was conducted on 2/12/13 at 10:20 AM with EI # 15, Registered Nurse (RN). During the observation EI # 15 turned off the water after washing hands, without using the paper towel. EI # 15 failed to follow the facility policy for hand-washing.

An interview was conducted on 2/13/13 at 1:40 PM with EI # 2, Chief Nursing Officer, who confirmed the above findings.





28327

Potter - Perry
Fundamentals of Nursing 6th Edition
Topical Medication Administration page 855

Skin Applications. Because many locally applied medications such as lotions, pastes, and ointments can create systemic and local effects, the nurse should apply these medications using gloves and applicators.



2. PI # 23 was admitted to the facility on 1/7/13 with diagnosis Percutaneous Endoscopic Gastrostomy (PEG) Tube Dysfunction.

Review of the physician's order written 2/6/13 revealed, "Clean wound to coccyx with wound cleanser, pack with a strip of Iodoform gauze & (and) cover q (every) day. Discontinue (D/C) Duoderm."

Review of the physician's order written 2/12/13 at 8:00 AM revealed, "Zinc and Xenaderm to open area to coccyx & cover daily and as needed (prn) soiled or dislodgement."

Review of the a wound photo dated 2/7/13 revealed, "Largest wound: width (W) 3.5 centimeters (cm), length (L) 5.5 cm. Smallest wound L 1.4 cm W 0.4 cm Depth (D) 3.5 cm."

The surveyor observed EI # 18, the RN perform wound care on 2/12/13 at 10:00 AM. EI # 18 removed the old dressing from the coccyx area, revealing 2 wounds. EI #18, removed the dirty gloves, cleansed his/her hands, then cleansed both wounds with wound cleanser, removed gloves, cleansed hands and applied new gloves. EI # 18, then packed the "tunneling" wound with Iodoform gauze. Using the same gloves, EI # 18 then applied the Zinc and Zenaderm ointment to the fingertips of the unchanged glove and applied the ointments to the surrounding area of both wounds. EI # 18 then applied a foam dressing.


EI # 18, failed to follow the procedures and perform each dressing change separately to prevent cross contamination when doing multiple wound dressing changes. EI # 18 failed to follow standards of nursing practice of applying topical ointments with the use of gloves and applicators.

During an interview on 2/13/13 at 10:30 AM, EI # 19, the Nurse Manager, verified the above aforementioned findings.


28969


3. PI # 30 was observed on 2/12/13 at 10:13 AM by the surveyor while EI # 20, Registered Nurse (RN)/Surgery, in Bay 4 of the Surgery Transitional Unit (STU) was preparing the patient for a cystoscopy with a possible biopsy.

Wearing clean gloves EI # 20 inserted a # 22 Gauge IV catheter into the patient's left arm, secured the IV catheter with tape and attached the IV line. Without removing his/her gloves or cleaning his/her hands, EI # 20 picked up the roll of tape on the overbed table, tore off another strip of tape and secured the IV line to the patient's arm. EI # 20 then placed the roll of tape back into the clean supply basket.

During an interview on 2/12/13 at 11:59 AM, EI # 21, RN/Director of Surgery, confirmed that once the gloves had been used to start the IV they were considered dirty and anything touched by these gloves after then would have been considered dirty. EI # 21 confirmed in this case the roll of tape should not have been placed back in the clean supply basket as the roll of tape was now dirty.



32470

4. PI # 31 was observed on 2/12/13 at 9:10 AM by the surveyor while EI # 14, RN dispensed medications to the patient. EI # 14 entered the room, donned gloves administered medication to the patient. EI # 14 exited the room with the computer, without removing gloves or washing his/her hands. Then EI # 14 obtained a cavi wipe and cleaned the computer key board and screen. EI # 14 then removed and disposed of the gloves.

At no time during the observation did EI # 14 perform hand washing or utilize hand sanitizer.

An interview on 2/13/13 at 1:50 PM with EI # 2 confirmed the above.


17650


Facility Policy: Accu-chek Inform Fingerstick Glucose
Revised 2/21/07
14.2 Procedure:
14.2.1. Wipe the surface of the Accu-check Inform System with a soft cloth slightly dampened (not wet) with one of the following solutions).
14.2.1.1. A freshly mixed solution of 1:10 bleach in water (1 part bleach in 9 parts water)
14.2.1.2. 70% isopropyl alcohol, full strength
13.2.1.3. Warm soapy water

A tour of the Wound Care Center was conducted on 2/13/13 at 10:30 AM. The surveyor observed a glucometer in the hyperbaric room. The surveyor asked EI # 24, Licensed Practical Nurse what the procedure was to clean the glucometer. EI # 24 stated to wipe it down with a Cavi wipe after each use. Review of the facility's policy revealed no documentation to use the Cavi wipe to clean the glucometer.

An interview was conducted with EI # 25, Director of the Wound Center on 2/13/13 at 10:45 AM who verified the policy was not being followed.



18155


5. PI # 9 was admitted to the Geri- Psych unit on 2/5/13 with a diagnosis of Dementia.

A wound care observation was conducted on 2/11/13 at 2:10 PM, with EI # 12, RN. Both wound beds were pink when the dressing was removed. EI # 12 removed the dressing and cleansed the two wound separately. EI # 12 applied Bactroban ointment to both wounds using the same strip of Kerlex as an applicator. The Bactroban should have been applied with a separate applicator for each wound to prevent cross contamination.

EI # 11, Geri- Psych Unit Director, was interviewed on 2/12/13 at 2:20 PM, and was asked where wound care would be documented. EI # 11 stated wound care would be located in the nursing assessment on admission and the shift assessment.

During an observation on 2/11/13 at 11:02 AM, EI # 12, RN, took a glucometer to an unsampled patient room and obtained a blood glucose reading. EI # 12 took the glucometer to the nurse station and placed in the charging area. EI # 12 did not clean the monitor prior to placing in the charger. EI # 12 was asked when the monitor was cleaned and EI # 12 stated the monitor was cleaned with "Cavi Wipe" prior to taking to patient room. The Cavi Wipe was not listed as approved for the cleaning of the glucometer and the glucometer should be cleaned after leaving a patient room to prevent cross contamination.




20228


A tour of the Emergency Department (ED) was conducted on 1/16/13 at 1:30 PM. The surveyor reviewed the ED logs for 2013 and requested 10 medical records to review.

During observation of care provided on 1/16/13 from 1:30 PM to 3:00 PM the surveyor observed the following:

1. Employee Identifier (EI) # 8, ED Nurse was observed placing linen in the dirty linen container with a gloved hand. EI # 8 then went back to the patient care area without hand hygiene.

2. EI # 8 then left the patient care area without hand hygiene and began documenting in the computer.

3. EI # 8 was observed obtaining blood via left antecubital space with a butterfly needle without gloves.

4. A step stool was observed in ED room # 101 with a red blood appearance stain.

5. Several rooms were observed being cleaned between patients. When the stretcher in each room was cleaned the staff did not clean under the mattress.

6. During observation of ED room 101 being cleaned between patients, a staff member was observed placing a urinal with approximately 200 cc (cubic centimeters) of urine in the regular trash.

An interview was conducted with EI # 7, ED Director on 1/16/13 at 2:45 PM. EI # 7 stated recognition of 1 of 10 ED records pulled by the surveyor. The surveyor asked which patient it was and the response was PI # 3. The surveyor then asked why he/she recognized PI # 3. EI # 7 stated that the Charge Nurse called him on 1/7/13 to inform EI # 7 of a incidence with PI # 3. EI # 7 stated that PI # 3 sat on the stretcher and a few minutes later realized her clothes were wet from the previous patient's urine. EI # 7 stated that the mattress was not cleaned underneath and the urine from the previous patient was left.



7. PI # 1 was admitted to the facility on 12/24/12 with admitting diagnoses including Cholecystitis, Possible Common Bile Duct Obstruction, Ileus, Hypertension, and Back Pain.


Review of the Operative Note dated 1/15/13 ( which should have been 1/14/13) revealed documentation as follows, "...we debrided the heel all the way down to the bone and bleeding tissue...It was a eschar with some wet and dry gangrene noted. We excised it all the way down to the bone...then the second toe on the right foot had what looked like an infection area over the top of the toe. I was able to debride it all the way down to the bleeding tissue..."

An interview with Employee Identifier ( EI) # 2, Chief Nursing Officer on 1/15/13/at 10:40 AM when the surveyor asked for wound measurements, photo, and description. EI # 2 was unable to locate any documentation of the wound description of any kind. EI # 2 stated there should have been photos on admission, measurements, descriptions of the wound and surrounding tissue.

On 1/16/13 at 7:50 AM the surveyor reviewed the medical record and there was no documentation of wound measurements, a photo, or a description.

The surveyor then requested to see the wound. EI # 2 and EI # 3 , Registered Nurse went to PI # 1's room with gauze and normal saline (NS). EI # 2 removed the dressing from the left heel. There was approximately a 5 cm (centimeter) ring of dried blood on the old dressing. EI # 2 threw the dressing in the regular trash. EI # 2 measured the wound 5 cm long, 4 cm wide, and 1/2 cm deep with blood red tissue. Bone was exposed.

EI # 2 cleansed the wound to the left heel and then covered the wound with gauze moistened with NS with the same pair of gloves used to remove the old dressing. EI # 3 then wrapped the wound to the left heel. EI # 3 then removed the dressing from the left great toe and was waiting for EI # 3 to return with more gauze. The left great toe was dripping blood on to the linen. EI # 3 then placed gauze under the toe to catch the dripping blood. After EI # 3 dressed the left great toe EI # 3 threw the gauze the toe had been dripping on in the regular trash.

EI # 3 then removed the dressing from the right 2nd toe with the same pair of gloves used to remove the dressing from the left great toe. EI # 3 then dressed the left great toe and the right 2nd toe using the same gloves.




Tonya Blankenship, Registered Nurse
Kay Bice, Registered Nurse
Carolyn Andreu, Registered Nurse
Michell Oliver, Registered Nurse
Tereasa Jackson, Registered Nurse
Judy Alexander, Registered Nurse
Cynthia Ball, Registered Nurse

Based on record review and interview, it was determined the governing body failed to ensure:

1. The Primary Physician followed up in 1 of 1 records reviewed where the patient's albumin level was low and the nutritional consult requested a nutritional supplement.

Refer to A 049

2. The patients were cared for in a safe environment including staff wearing gloves, handwashing and clean equipment.

Refer to A 144

3. The Nursing staff:

A. Provided wound care as ordered

B. Provided an initial assessment of the patients with wounds

C. Provided an ongoing assessment of the patients with wounds.

D. Followed the Facility Policy for wound care.

E. Followed Drug Interaction Standards for wound care.

Refer to A 395

4. All infection control policies and standards were followed by the staff.

Refer to A 748


This affected 7 of 7 records reviewed with wounds Patient Identifer # 15, 23, 30, 31, 9, and 1 and had the potential to negatively affect all patients with wounds.

Based on record review and interview, it was determined the governing body failed to ensure the Primary Physician followed up in 1 of 1 records reviewed where the patient's albumin level was low and the nutritional consult requested a nutritional supplement. This negatively affected Patient Identifer (PI) # 1 and had the potential to negatively affect all patients served by this facility.

Findings include:

1. PI # 1 was admitted to the facility on 12/24/12 with diagnoses including Cholecystitis, Possible Common Bile Duct Obstruction, Ileus, Hypertension, and Back Pain.

Review of the laboratory results dated 12/25/12 at 4:48 AM revealed a albumin level of 2.30 (normal 3.5 to 5.00).

Review of the Nutritional Assessment dated 12/26/12 at 3:20 PM revealed recommendations by the Dietician as follows:
Dental Soft diet
Ensure TID (three times a day) as a nutritional supplement
Monitor weights, labs, intake and output
Continue multivitamin and Oscal D BID (twice a day).

Review of the progress notes dated 12/27/12 at 3:20 PM revealed documentation the Nutritional Services had Nutritional recommendations under the Dietary Tab.

Review of the Nutritional Assessment dated 12/31/12 at 2:00 PM revealed the following documentation by the Dietician :
No weight recorded, no D/U (Decubitus Ulcer) per flowsheet
Diet: Dental Soft with < 30% intake
Dietitian's Note recommended the following:
Continue Dental Soft diet
Assist in menu selection, tray set-up. Encourage intake of food and fluids.
Honor all food preferences per diet order.
Add Ensure TID with meals
Monitor weights, labs, intake and output
Add Oscal D BID.

Review of the progress notes dated 12/31/12 at 2:00 PM revealed documentation the Nutritional Services had Nutritional recommendations under the Dietary Tab. There were 14 entries per physicians in the progress notes between 12/27/12 and 12/31/12 Dietary entries.

Review of the Nutritional Assessment dated 1/5/13 at 5:35 PM revealed the following documentation by the Dietician :
No weight recorded, no D/U per flowsheet
Diet: Dental Soft with very poor intake reported by patient and no intake recorded. Patient request soup with lunch and dinner trays...
Dietitian's Note recommended the following:
Continue Dental Soft diet encourage intake
Assist in menu selection in AM, help with tray set-up. Encourage intake of food and fluids.
Honor all food preferences.
Add Ensure TID with meals
Monitor weights, labs, intake and output
Oscal D BID.

Review of the progress notes dated 1/5/13 at 5:35 PM revealed documentation the Nutritional Services had Nutritional recommendations under the Dietary Tab. There were 15 entries in the progress notes per physicians between 12/31/12 and 1/5/13 Dietary entries.

Review of the Nutritional Assessment dated 1/10/13 at 4:10 PM revealed the following documentation by the Dietician :
No weight recorded, no D/U per flowsheet
Diet: Mechanical Soft
Dietitian's Note recommended the following:
Continue diet encourage intake.
Patient may benefit from appetite stimulant
Check Prealbumin
Continue multivitamin
Monitor weights, labs, intake and output.

Review of the Vital Signs/I (intake) and O (output) Record between 12/24/12 and 1/14/13 revealed no documentation of the amount of meal consumption by the patient.

Review of the Physician Orders and Medication Administration Record revealed the following:

1. No documentation the physician ordered a dietary supplement three times a day with meals.

2. No documentation the physician ordered a weight check.

3. No documentation of an Albumin assessment after 12/25/12.

4. No documentation of an appetite stimulant until 1/13/13.

5. No documentation of an order to monitor the patient's meal consumption.

An interview was conducted with Employee Identifier (EI) # 1, Primary Physician on 1/16/13 at 7:40 AM. The surveyor asked EI # 1 if he/she was aware the Dietician made three different recommendations for Ensure 3 times a day and was there a reason the Ensure was not ordered? EI # 1 stated he/she was not aware of the ensure recommendation.

Review of PI # 1's medical record on 1/16/13 at 8:00 AM revealed an order from EI # 1 at 7:50 AM for Ensure or Boost three times a day.

The governing body failed to ensure the Primary Physician reviewed all recommendations made by the Nutritional Consultant.

Based on observations and interviews it was determined the facility failed to ensure the patients were cared for in a safe environment including staff wearing gloves, handwashing and clean equipment. This affected Patient Identifer (PI) # 3 and had the potential to negatively affect all patients served by this facility.

Findings include:

A tour of the Emergency Department (ED) was conducted on 1/16/13 at 1:30 PM. The surveyor reviewed the ED logs for 2013 and requested 10 medical records to be reviewed by the surveyor.

During observation of care provided on 1/16/13 from 1:30 PM to 3:00 PM the surveyor observed the following:

1. Employee Identifier (EI) # 8, ED Nurse was observed placing linen in the dirty linen container with an ungloved hand. EI # 8 then went back to the patient care area without hand hygiene.

2. EI # 8 then left the patient care area without hand hygiene and began documenting in the computer.

3. EI # 8 was observed obtaining blood via left antecubital space with a butterfly needle without gloves.

4. A step stool was observed in ED room # 101 with a reddish ring stain approximately 6 cm (centimeter) in diameter.

An interview was conducted with EI # 7, ED Director on 1/16/13 at 2:45 PM. EI # 7 stated recognition of 1 of 10 ED records requested by the surveyor. The surveyor asked which patient it was and the response was PI # 3. The surveyor then asked why he/she recognized PI # 3. EI # 7 stated that the Charge Nurse called on 1/7/13 to inform EI # 7 of a incidence with PI # 3. EI # 7 stated that PI # 3 sat on the stretcher and a few minutes later realized her cloths were wet from the previous patients urine. EI # 7 stated that the mattress was not cleaned underneath and the urine was from the previous patient.

Based on review of medical records, Potter - Perry Fundamentals of Nursing, facility policies and procedures, and drug interaction standards and interviews with administrative staff, it was determined the nursing staff failed to:

1. Provide wound care as ordered

2. Provide an initial assessment of the patients with wounds

3. Provide an ongoing assessment of the patients with wounds.

4. Follow the Facility Policy for wound care.

5. Follow Drug Interaction Standards for wound care.


This affected 2 of 2 records reviewed before 2/11/13 with wounds Patient Identifer # 1 and 2 and had the potential to negatively affect all patients with wounds.

Refer to A 395

Based on review of medical records, Potter - Perry Fundamentals of Nursing, facility policies and procedures, and interviews with staff, it was determined the nursing staff failed to:

1. Provide wound care as ordered

2. Provide an initial assessment of the patients with wounds

3. Provide an ongoing assessment of the patients with wounds.

4. Follow the Facility Policy for wound care.

5. Follow Drug Interaction Standards for wound care


This affected 2 of 2 records reviewed before 2/11/13 with wounds (Patient Identifer (PI) #s 1 and 2) and had the potential to negatively affect all patients with wounds.

Findings include:

Facility Policy: Assessment and Reassessment of Patients by Nursing Staff issued 4/5/10

1. Purpose: To establish guidelines for the admission assessment and reassessment of patients by the nursing staff to Medical West.

3. Standards:

3.1.2 The Admission Assessment is the responsibility of the registered nurse. The registered nurse will assess the patient upon admission.

3.1.4 The assessment data will be utilized in the development of the individualized nursing care plan.

3.1.5 The assessment may be accomplished through interview and observation of the patient, family and/or significant other and through review of other pertinent data such as; history and physical, x-ray reports, laboratory reports, previous admissions records and physician notes.

3.1.6 The admission assessment will include factors influencing nursing care or discharge planning, such as, a significant past medical history, age related factors, social history, presence or absence of pain, personal factors and a systems assessment.

4. PROCEDURE/CRITERION CHECKLIST:

Procedure Steps/Critical Elements: Admission assessment

1. COMPLETE ADMISSION ASSESSMENT AND HEALTH HISTORY...

Complete Skin Assessment

************
Policy Title: Assessment, Skin and Wounds, Written 7/6/06, Reviewed 3/5/10 and Revised 2/5/11.


Purpose: To establish guidelines for skin and wound assessment.
Standards:
3.6 Observation of dressing and/or wound shall be done...at least once per shift for length of hospital stay.
3.9 A Braden Skin Assessment shall be performed on admission and patients with a score of 16 or less will have high risk interventions implemented as directed in the Preventative Skin Care Guide.

**********
Braden Scale Protocol Interventions

Risk Factor 16 and below, Skin is broken HIGH RISK INTERVENTIONS

17. Order Wound Consult

18. All care should start ON admission. MEASURE ALL wounds, take photo and (place) in progress notes

************

Information from Drugs.com

Drug interactions between Grafco Silver Nitrate (Silvadene) and Santyl

Generally Avoid: The enzymatic activity of collagenase (santyl) may be adversely affected by heavy metal ions such as mercury and silver, which are found in some antiseptics. The mechanism of interaction has not been described.

Management: Topical preparations containing heavy metals such as silver and mercury should not be used on wounds treated with collagenase. When it is suspected such products have been used, the site should be carefully cleansed by repeated washings with normal saline before application of collagenase.

************

Facility Policy: Dressing Change Issued 4/5/10

1. Purpose: To establish guidelines for wound dressing changes.

2. Philosophy: It is our belief that proper wound dressing changes minimize the potential for infection and promote patient comfort and wound healing.

3. Standards:

3.5. Universal Precautions shall be followed during dressing change.

4. Procedure:

4.6. When doing multiple wound dressing changes, follow procedures and do each dressing change separately to prevent cross contamination.

4.7. Wash Hands

4.8. Put on non-sterile gloves.

4.10. Remove soiled dressing and place in plastic bag.

4.11. Remove soiled gloves.

4.12. Wash hands.

4.14. Apply gloves.

************

Facility Policy: Infection Control

OSHA (Occupational Safety and Health Administration) Bloodborne Pathogen Standard

Exposure Control Plan dated 7/30/08

Standard Precautions

1. Healthcare Personnel Hand-Washing

4. Decontaminate hands in the following situations:

h. After removing gloves...

III. Gloves:

B. Gloves must be worn:

1. When there is likelihood of hand contact with blood and any secretions or other potentially infectious materials.

2. During all vascular access procedures.

**********
Potter - Perry
Fundamentals of Nursing
6th Edition
Topical Medication Administration page 855

Skin Applications. Because many locally applied medications such as lotions, pastes, and ointments can create systemic and local effects, the nurse should apply these medications using gloves and applicators. ...Simply applying new medications over previously applied medications does little to prevent infection or offer therapeutic benefit. Before applying medications, the nurse cleanses the skin thoroughly ...

Potter - Perry
Fundamentals of Nursing
7th Edition
Chapter 48 Skin Integrity and Wound Care page 1311 - 1312

Cleansing: The process of cleansing a wound involves selecting both an appropriate cleansing solution and using a mechanical means of delivering that solution without causing injury to the healing wound tissue (WOCN, [Wound Ostomy and Continence Nurses Society] 2003).

Dressings: ...The correct dressing selection facilitates wound healing... The dressing type depends on the assessment of the wound and the phase of the wound healing. ...A wound that requires infection management requires a different set of dressing than a wound requiring the removal of nonviable tissue.

Types of Dressings. ...Pressure ulcers require dressings. The type of dressing is usually based on the stage of the pressure ulcer...



20228

1. PI # 1 was admitted to the facility on 12/24/12 with admitting diagnoses including Cholecystitis, Possible Common Bile Duct Obstruction, Ileus, Hypertension, and Back Pain.

Review of the Present on Admission Assessment from the Emergency Department dated 12/24/12 at 1:00 PM revealed documentation of a pressure ulcer to the right and left heel. There was no documentation of a measurement, description or photo.

Review of the RN (Registered Nurse) Physical Assessment and History Data dated 12/24/12 at 3:16 PM revealed the following documentation:

No edema, rash, bruises/hematoma, abrasions, lacerations, or fungus

Other Skin Ulcers/lesions (not due to pressure) N (no)

Pressure Ulcer Present on Admission N

Does patient have an open draining wound N

Review of the Plan for Nursing Care: Medical/Surgical Patient revealed no documentation for a goal or intervention under alteration in Healing related to wounds.

Review of the twenty one 24 Hour Flow Sheets dated between 12/24/12 and 1/13/13 revealed no documentation of a dressing change/location, drainage amount & color, or wound appearance for the wounds to the left and right heel.

There was no documentation in the medical record of the patient's pressure ulcers to the left or right heel until 1/12/13 at 12 noon when the daughter asked about the condition of the patient's left heel due to complaints of pain.

Review of the Physician's Order dated 1/12/13 at 5:10 PM revealed an order for General Surgery Consult concerning left foot pain (area on heel).

Review of the Physician's Order dated 1/13/13 at 6:50 AM revealed orders for an I & D (incision and drain) of left heel, removal of the left great toe nail and an I&D 2nd toe nail to be completed 1/14/13.

Review of the Consultation Report dated 1/13/13 revealed patient had been complaining the left heel was sore and found to have a left heel decubitus.

Review of the Operative Note dated 1/15/13 ( which should have been dated 1/14/13) revealed documentation as follows, "...we debrided the heel all the way down to the bone and bleeding tissue...It was a eschar with some wet and dry gangrene noted. We excised it all the way down to the bone...then the second toe on the right foot had what looked like an infection area over the top of the toe. I was able to debride it all the way down to the bleeding tissue..."

Review of the Nurse Note dated 1/14/13 revealed the patient was off the floor to surgery at 9:00 AM and returned to the floor at 4:00 PM.

Review of the Nurse Notes dated 1/15/13 at 9:00 AM revealed the nurse changed the dressing to the left heel.

The medical record was reviewed by the surveyor on 1/15/13 at 10:00 AM. There was no documentation of a decubitus to the left heel until 1/12/13 when the patient began complaining of pain to the left heel. There was no documentation of the left heel wound size, appearance or condition of the surrounding tissue.

In an interview with Employee Identifier ( EI) # 2, Chief Nursing Officer on 1/15/13 at 10:40 AM, when the surveyor asked for wound measurements, photo, and description. EI # 2 was unable to locate any documentation of the wound description of any kind. EI # 2 stated there should have been photos on admission, measurements, descriptions of the wound and surrounding tissue.

On 1/16/13 at 7:50 AM the surveyor reviewed the medical record and there was no documentation of wound measurements, a photo, or a description.

The surveyor then requested to see the wound. EI # 2, Chief Nursing Officer and EI # 3 , Registered Nurse went to PI # 1 room with gauze and normal saline (NS). EI # 2 removed the dressing from the left heel. There was approximately a 5 cm (centimeter) ring of dried blood on the old dressing. EI # 2 threw the dressing in the regular trash. EI # 2 measured the wound 5 cm long, 4 cm wide, and 1/2 cm deep with blood red tissue. Bone was exposed.

EI # 2 cleansed the wound to the left heel with the same pair of gloves used to remove the old dressing, using NS and gauze. EI # 2 then covered the wound with gauze moistened with NS, removed the gloves and EI # 3 then wrapped the wound. EI # 3 then removed the dressing from the left great toe and was waiting for EI # 3 to return with more gauze. The left great toe was dripping blood on to the linen. EI # 3 placed gauze under the toe to catch the dripping blood. After EI # 3 dressed the left great toe EI # 3 threw the gauze the toe had been dripping on in the regular trash.

EI # 3 then removed the dressing from the right 2nd toe with the same pair of gloves used to remove the dressing from the left greater toe. EI # 3 then dressed the left greater toe and the right 2nd toe with the same gloves.

An interview was conducted with EI # 2 on 1/15/13 at 11:00 AM. The surveyor asked if the PI # 1 received a consult with a wound nurse. EI # 2 stated they did not have a wound nurse at present but did use a Nurse Manager as a resource if needed. The surveyor asked if the resource person had seen PI # 1 and the response was no.

2. PI # 2 was admitted to the facility on 12/26/12 with diagnoses including Cancer of the Lung and Wounds to Bilateral Feet.

Review of the Physician's order dated 12/26/12 at 9:00 AM revealed orders for the nurse to remove dressings on lower extremities (LE) and assess and wash the wounds. Wash the lower extremities daily apply Bactroban cream, nonocclusive dressing and wrap.

Review of the Medication Administration Record (MAR) and the Nurse Note dated 12/26/12 revealed no documentation the nurse washed the LE, applied Bactroban cream, nonocclusive dressing and wrapped.

Review of the Physician's Order dated 12/28/12 at 7:15 AM revealed orders for the staff to treat both foot wounds daily with Santyl - apply a layer "nickle - thick" and wet to dry dressing on top of both - then wrap feet with kerlix.

Review of the physician's order dated 12/29/12 at 4:45 PM revealed orders for silvadene dressings to both foot wounds now and daily.

Review of the MAR and the Nurse Note dated 12/29/12 revealed no documentation the staff applied silvadene to both wounds on the feet.

Review of the MARs dated 12/30/12, 12/31/12, 1/1/13, and 1/2/13 revealed documentation the nurses applied both santyl and silvadene.

Review of the physician's order dated 1/3/13 at 1:00 PM revealed orders for the following dressing changes. Apply Santyl to both foot wounds daily with wet to dry dressings and Kerlix wrap.

Review of the MARs dated 1/3/13, 1/4/13, 1/5/13, 1/6/13, 1/7/13, 1/8/13, 1/9/13, 1/10/13, 1/11/12, 1/12/13, 1/13/13, 1/14/13, and 1/15/13 revealed documentation the nurses applied both santyl and silvadene.

An interview was conducted with EI # 4, Pharmacist on 1/13/13 at 11:35 AM. The surveyor asked why the staff continued to apply Santyl and Silvadene, did one not counter act the other. The response was the pharmacy staff were not told to stop one wound care to begin another.

An interview was conducted with EI # 6, Surgeon on 1/16/13 at 12:30 PM. The surveyor asked if EI # 6 expected the staff to stop using one wound care order before starting another. EI # 6 stated, "Yes I would. They did didn't they?" The surveyor told EI # 6 that the staff were using both Santyl and Silvadene at the same time. EI # 6 stated, "Oh no."

Based on a review of medical records and interview with staff, it was determined the facility failed to update or revise the nursing care plan with up to date information from ongoing patients' assessments. This had the potential to affect all patients served by the facility and did affect Patient Identifiers (PI) #s 11, 7, 21, 22, 9 and 15, which was 6 of 24 records reviewed.

Findings include:

Facility Policy: Plan of Care
Issued: 2/4/13

4. Standards: ...

4.3 The plan will be reviewed daily and revised in response to patient care needs and expected outcomes.

4.4 The Plan of Care will communicate information about the needs/problems of the patient and guide the health care team in the provision of nursing care.

4.5 The Care Plan will: ...

4.5.2 Include the medical plan of care

4.5.3 Be consistent with ancillary departments therapies

4.5.4 Be readily available to the health care team

4.5.5 Be used in patient care conferences, discharge planning meetings and change of shift reports...

4.6.6 Being congruent with the therapy prescribed by the physician...

4.7 The Plan of Care will include the specific patient needs, goals nursing orders that will promote and maintain the patient's maximum potential by:

4.7.2 Identifying and documenting patient problems and required nursing interventions, on the nursing care plan.

4.7.3 Formulating patient goals that are realistic, measurable and mutually developed with the patient, family and/ or significant other when possible...

4.9 Utilization of the Plan of care and the patient's response to the care given will be recorded in the patient's medical record by:

4.9.1 Documenting implementation of medical therapy and nursing interventions.

4.9.2 Documenting the patient's response to care received.

4.9.3 Documenting the evaluation of goals and nursing interventions.

4.10 Review of the care plan shall be completed daily

4.10.1 Care plans are updated with the 24 hour flow sheet...

4.10.2 To indicate review of the Care Plan by RN (Registered Nurse) when no revisions are indicated write in care plan section "Reviewed continue care plan of" and the date.


1. PI # 11 was admitted to the facility 2/8/13 with abdominal pain. On 2/10/13 the patient underwent surgery for a Cholecystectomy and Hernia Repair.

The plan of care established 2/8/13 was as follows:

Patient Problem/Diagnosis: "Alteration in Comfort r/t (related to) Abdominal Pain"

Goal: "Patient will verbalize acceptable level of comfort"

Planned Nursing Interventions:
Assess for discomfort using pain scale q (every)_____ and document;
Administer pain medication per MD (Medical Doctor) orders,
Reassess for effectiveness of pain medication and document,
Consult with MD if ordered medications are not effective

The Nursing Care Plan was reviewed 2/9/13 and 2/11/13 with no additional patient problems/diagnoses identified.

An interview with EI # 2, Chief Nursing Officer (CNO) on 2/13/12 at 1:45 PM confirmed the Nursing Care Plans were not updated and patient specific.




18155

2. PI # 7 was admitted to the facility on 1/23/13 with a diagnosis of Abnormal Coagulation and Coumadin Toxicity.

There was one undated photo of the wound to the left hand in the medical record. The photo included a small measurement instrument held up to the left hand wound and it indicated the wound was 2 cm. in length. There was no width or depth measured.

The Care Plan dated 1/23/13 contained documentation there was "No break in Skin". The nurse did not include the break in skin in PI # 4's Care Plan.


EI # 2, was interviewed on 2/13/13 at 1:42 PM who verified the Care Plan did not contain documentation the patient had a wound.

The "Patient Intervention Activity Sheet" dated 1/23/13 contained documentation PI # 4 had a "Bruise ... Abrasion" to left hand.

The "Patient Assessment" dated 1/23/13 at 8:00 PM, contained documentation, "Changed dressing and secure with tape." The documentation did not indicate where the wound was located, what the wound was cleaned with prior to applying a dressing, what type of dressing was applied, or measurements/ description of the wound. There was no physician order for wound care to the left hand found in the medical record.

The "Patient Assessment" dated 1/24/13 at 4:20 AM, contained documentation, "Changed dressing to LT (left) hand." The documentation did not indicate where the wound was located, what the wound was cleaned with prior to applying a dressing, what type of dressing was applied, or measurements/ description of the wound.

EI # 2, was interviewed on 2/13/13 at 1:42 PM who verified the Care Plan did not contain documentation the patient had a wound.

3. PI # 21 was admitted to the facility Geri-Psych Unit on 2/10/13 with a diagnosis of Bipolar Disorder and Major Depression.

The "Psychosocial Report" dated 2/12/13 identified, "When asked how he spends his free time, he says he spends his free time reading, praying, golfing, and building puzzles."

The Unit Schedule was posted in the Activity/Dining area:

9-11:30 OT (Occupational Therapy)
12- 1 Lunch
1-2 Visitation
2- 3:30 SW (Social Worker) Group/ Chaplain
3:30 - 4 Patient Education Group
4:30 - 5:30 Supper
5:30 - 6:30 Visitation
7 - 8 Relaxation Group

During an observation on 2/11/13 at 11:15 AM, PI # 21 was watching TV with another male patient.

PI # 21 was observed again on 2/11/13 lying in the bed at 2:00 PM.

During an observation on 2/11/13 at 2:35 PM, EI # 27, Geri- Psych Unit Secretary, was asked where the Social Worker was located. EI # 27 stated the Social Worker was gone to lunch and would be back. The SW was at lunch during the scheduled SW/ Chaplain group scheduled for 2:00 - 3:30 PM. There was no group meeting in the activity/dining area. The patients were observed walking in hallway, watching TV, or in their rooms.

The OT, EI # 26, was observed leading a group on 2/12/13 at 10:00 AM. There were 6 patients in the group with 3 patients resting with eyes closed. EI # 26 attempted to engage each patient by calling the patient by name but with little response. The group ended at 10:20 AM. PI # 21 was a part of the group but did not interact with EI # 26 or other patients.

The Geri-Psych Unit Director, EI # 11, on 2/13/13 at 9:47 AM informed the surveyor OT saw patients in the main hospital also and should be on unit soon.

During an observation on 2/13/13 at 10:00 AM the OT Group started.

EI # 26 did not arrive to the unit until 10:00 AM both days of observation. The group was to begin at 9:00 AM.

PI # 21 was interviewed on 2/13/13 at 10:30 AM. PI # 21 stated he was bored most of the time. He was asked what type of activities had the staff offered and he stated the staff had not offered anything but the TV and to rest in his room. He also stated, "I don't have much in common with the other patients. " The surveyor asked if the staff had offered puzzles, books or anything else he might be interested in and he stated, "No."

The staff did not adhere to the stated schedule of OT from 9:00 - 11:30. The staff also did not Care Plan individualized activities for PI # 21.

The Care Plan for PI # 21 was initiated on 2/10/13. One of the Goals was "Pt will verbalize knowledge and acceptance of the need for continued therapy, chemotherapy, regular blood test, and so forth." PI # 21 was not taking chemotherapy. The interventions listed for this goal did not include what blood test would be scheduled and what type of chemotherapy PI # 21 needed knowledge of and how to achieve acceptance.

Another Goal listed on the 2/10/13 Care Plan "Mental Status: is maintained at pt's maximum attainable level of functioning". The Interventions listed were:

Communication- Provide Alternative
Use yes/no questions
Use simple words, short sentences
Utilize eye blink
Utilize lip reading
Utilize sign language
Utilize pen/paper
Provide picture board
Communication by gesture

These interventions were listed for a patient who could easily communicate with words and complex ideas. These interventions were not appropriate for PI # 21.

4. PI # 22 was admitted to the facility Geri-Psych Unit on 2/6/13 with a diagnosis of rule out Delirium and Psychotic Disorder.

During an observation on 2/11/13 at 10:15 AM revealed PI # 22 had a vest restraint and was in a Gerichair with the foot rest raised.

During an interview with EI # 11, Unit Director, on 2/11/13 at 11:02 stated PI # 22 had fallen at home and had a black eye and a small cut to forehead from the fall at home.

A review of the Care Plan Dated 2/6/13 revealed there was no documentation PI # 22 had a vest restraint or Gerichair for PI # 22's protection form Falls.

5. PI # 9 was admitted to the Geri- Psych unit on 2/5/13 with a diagnosis of Dementia.

A "Physician's Order" dated 2/5/13 at 7:40 PM, contained documentation, " Continue wound care- Vaseline gauze dressing- Bactroban cream to area PRN (when needed)." This order did not specify PI # 6 had two wounds, where the wounds were located, what type of cleansing agent to use, or what type of dressing to apply over the Vaseline gauze to cover the 2 burn wounds.

The Care Plan dated 2/6/13 had a problem identified as "Skin Integrity Alteration R/T (related to) Pt (patient) has a burn to Left Arm." This did not identify PI # 9 had two wounds to the left forearm. The intervention for this problem was "Wound Care: Dressing Change daily. Assess wound daily for any s/s (signs and symptoms) of infection. Assessment: Shift." There was no documentation in the medical record PI # 9 had two wounds to the left forearm, a daily wound description, or measurements of the two wounds.


32470



5. PI # 15 was admitted to the facility on 2/8/13 with diagnoses of UTI(Urinary Track Infection), Positive Escherichia Coli Infection and a wound to the Left Ankle.

Review of the RN (Registered Nurse) assessment dated 2/8/13 at 4:41 PM revealed the patient had a draining wound to the "left lateral leg at ankle".

Further review of the medical record revealed the patient pain was "4" on a scale of 0-10 with 0 being no pain and 10 severe pain.


The nurses documented on 2/8/13 at 7:06 PM the patient had 2 to 3 plus edema to the lower extremities and the patient reported "numbness in the lower extremities".


On 2/12/13 the surveyor observed EI # 15, Registered Nurse (RN), perform wound care. Upon entering patients room the patient stated "I'm in pain but I guess I can wait until you finished my dressing change."


The Plan for Nursing Care dated 2/8/12 revealed the following: "Alteration in skin integrity related to wound left lateral leg."


The Plan of Nursing Care was not updated or initiated for Alteration in comfort, or Risk for fall.


An interview with EI # 2 on 2/13/12 at 1:40 PM confirmed the Plan for Nursing Care was not initiated specific to all the patients problems/needs and updated timely.

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:

Refer to the Life Safety Code survey report for findings.

Based on observations and interviews it was determined the infection control officer failed to ensure all infection control policies and standards were followed by the staff. This affected Patient Identifer # 1, 3, 9, 15, 23, 28, 30 and 31 and had the potential to negatively affect all patients served by this facility.



Refer to A 748

Based on observations and interviews it was determined the infection control officer failed to ensure all infection control policies and standards were followed by the staff. This affected Patient Identifer (PI) # 15, 23, 30, 31, 9 and 1 and had the potential to negatively affect all patients served by this facility.

Findings Include:


Facility Policy: Dressing Change Issued 4/5/10

1. Purpose: To establish guidelines for wound dressing changes.

2. Philosophy: It is our belief that proper wound dressing changes minimize the potential for infection and promote patient comfort and wound healing.

3. Standards:

3.1. Dressing changes shall be initiated by physician's orders.

3.1.1. Dressing change procedure shall be followed when order is written for "Dressing Change" unless otherwise specified by M.D. in order.

3.4. Wounds will be assessed during dressing change for signs of healing and/or complications such as odor, redness, swelling, color and type of any drainage and approximation of wound edges.

3.4.2. Description of wound shall be documented in the patient's medical record.

3.5. Universal Precautions shall be followed during dressing change.

4. Procedure:

4.6. When doing multiple wound dressing changes, follow procedures and do each dressing change separately to prevent cross contamination.

4.7. Wash Hands

4.8. Put on non-sterile gloves.

4.10. Remove soiled dressing and place in plastic bag.

4.11. Remove soiled gloves.

4.12. Wash hands.

4.14. Apply gloves.

************

Policy: Hand - Washing and Standard Precautions Issued 7/11/05

Philosophy: It is our belief that using Standard Precautions on all patients receiving care in the hospital will reduce the risk of hospital-acquired infections.

Procedures:

5.1 Hand Hygiene

5.1.3. Indications for Hand washing and Hand Antisepsis shall include:
5.1.3.1. Before having direct contact with patients.
5.1.3.2. Before donning gloves and performing an invasive procedure.
5.1.3.3. After removing gloves or other personal protective equipment.
.........

5.1.5. Hand washing Procedure with Liquid or Foam Soap:

5.1.5.6. Use paper towel to turn off faucet.

************

Centers for Disease Control (CDC) Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings

What Type of PPE Would You Wear?

Drawing blood from a vein? Gloves

************
CDC Guidelines for Bloodborne Pathogens
by Beth Celli, eHow Contributor

Bloodborne Pathogens

Bloodborne pathogens are microscopic organisms (or microorganisms) that can cause illness in people. They are found in the blood or other body fluids. Human immunodeficiency virus (HIV) which causes AIDS, and hepatitis B virus (HBV), are two of the most common bloodborne pathogens. These diseases and others pose a serious threat to health care workers.

Management of Waste

All materials that are contaminated with blood or body fluids should be disposed of in a red bag, or biohazard trash...

************
Facility Policy: Infection Control

OSHA (Occupational Safety and Health Administration) Bloodborne Pathogen Standard

Exposure Control Plan dated 7/30/08

Standard Precautions

1. Healthcare Personnel Hand-Washing

4. Decontaminate hands in the following situations:

h. After removing gloves...

III. Gloves:

B. Gloves must be worn:

1. When there is likelihood of hand contact with blood and any secretions or other potentially infectious materials.

2. During all vascular access procedures.


PI Findings Include:

1. PI # 15 was admitted to the facility on 2/8/13 with diagnoses of UTI(Urinary Track Infection), Positive Escherichia Coli Infection and a wound to the Left Ankle.

An observation of wound care was conducted on 2/12/13 at 10:20 AM with EI # 15, Registered Nurse (RN). During the observation EI # 15 turned off the water after washing hands, without using the paper towel. EI # 15 failed to follow the facility policy for hand-washing.

An interview was conducted on 2/13/13 at 1:40 PM with EI # 2, Chief Nursing Officer, who confirmed the above findings.





28327

Potter - Perry
Fundamentals of Nursing 6th Edition
Topical Medication Administration page 855

Skin Applications. Because many locally applied medications such as lotions, pastes, and ointments can create systemic and local effects, the nurse should apply these medications using gloves and applicators.



2. PI # 23 was admitted to the facility on 1/7/13 with diagnosis Percutaneous Endoscopic Gastrostomy (PEG) Tube Dysfunction.

Review of the physician's order written 2/6/13 revealed, "Clean wound to coccyx with wound cleanser, pack with a strip of Iodoform gauze & (and) cover q (every) day. Discontinue (D/C) Duoderm."

Review of the physician's order written 2/12/13 at 8:00 AM revealed, "Zinc and Xenaderm to open area to coccyx & cover daily and as needed (prn) soiled or dislodgement."

Review of the a wound photo dated 2/7/13 revealed, "Largest wound: width (W) 3.5 centimeters (cm), length (L) 5.5 cm. Smallest wound L 1.4 cm W 0.4 cm Depth (D) 3.5 cm."

The surveyor observed EI # 18, the RN perform wound care on 2/12/13 at 10:00 AM. EI # 18 removed the old dressing from the coccyx area, revealing 2 wounds. EI #18, removed the dirty gloves, cleansed his/her hands, then cleansed both wounds with wound cleanser, removed gloves, cleansed hands and applied new gloves. EI # 18, then packed the "tunneling" wound with Iodoform gauze. Using the same gloves, EI # 18 then applied the Zinc and Zenaderm ointment to the fingertips of the unchanged glove and applied the ointments to the surrounding area of both wounds. EI # 18 then applied a foam dressing.


EI # 18, failed to follow the procedures and perform each dressing change separately to prevent cross contamination when doing multiple wound dressing changes. EI # 18 failed to follow standards of nursing practice of applying topical ointments with the use of gloves and applicators.

During an interview on 2/13/13 at 10:30 AM, EI # 19, the Nurse Manager, verified the above aforementioned findings.


28969


3. PI # 30 was observed on 2/12/13 at 10:13 AM by the surveyor while EI # 20, Registered Nurse (RN)/Surgery, in Bay 4 of the Surgery Transitional Unit (STU) was preparing the patient for a cystoscopy with a possible biopsy.

Wearing clean gloves EI # 20 inserted a # 22 Gauge IV catheter into the patient's left arm, secured the IV catheter with tape and attached the IV line. Without removing his/her gloves or cleaning his/her hands, EI # 20 picked up the roll of tape on the overbed table, tore off another strip of tape and secured the IV line to the patient's arm. EI # 20 then placed the roll of tape back into the clean supply basket.

During an interview on 2/12/13 at 11:59 AM, EI # 21, RN/Director of Surgery, confirmed that once the gloves had been used to start the IV they were considered dirty and anything touched by these gloves after then would have been considered dirty. EI # 21 confirmed in this case the roll of tape should not have been placed back in the clean supply basket as the roll of tape was now dirty.



32470

4. PI # 31 was observed on 2/12/13 at 9:10 AM by the surveyor while EI # 14, RN dispensed medications to the patient. EI # 14 entered the room, donned gloves administered medication to the patient. EI # 14 exited the room with the computer, without removing gloves or washing his/her hands. Then EI # 14 obtained a cavi wipe and cleaned the computer key board and screen. EI # 14 then removed and disposed of the gloves.

At no time during the observation did EI # 14 perform hand washing or utilize hand sanitizer.

An interview on 2/13/13 at 1:50 PM with EI # 2 confirmed the above.


17650


Facility Policy: Accu-chek Inform Fingerstick Glucose
Revised 2/21/07
14.2 Procedure:
14.2.1. Wipe the surface of the Accu-check Inform System with a soft cloth slightly dampened (not wet) with one of the following solutions).
14.2.1.1. A freshly mixed solution of 1:10 bleach in water (1 part bleach in 9 parts water)
14.2.1.2. 70% isopropyl alcohol, full strength
13.2.1.3. Warm soapy water

A tour of the Wound Care Center was conducted on 2/13/13 at 10:30 AM. The surveyor observed a glucometer in the hyperbaric room. The surveyor asked EI # 24, Licensed Practical Nurse what the procedure was to clean the glucometer. EI # 24 stated to wipe it down with a Cavi wipe after each use. Review of the facility's policy revealed no documentation to use the Cavi wipe to clean the glucometer.

An interview was conducted with EI # 25, Director of the Wound Center on 2/13/13 at 10:45 AM who verified the policy was not being followed.



18155


5. PI # 9 was admitted to the Geri- Psych unit on 2/5/13 with a diagnosis of Dementia.

A wound care observation was conducted on 2/11/13 at 2:10 PM, with EI # 12, RN. Both wound beds were pink when the dressing was removed. EI # 12 removed the dressing and cleansed the two wound separately. EI # 12 applied Bactroban ointment to both wounds using the same strip of Kerlex as an applicator. The Bactroban should have been applied with a separate applicator for each wound to prevent cross contamination.

EI # 11, Geri- Psych Unit Director, was interviewed on 2/12/13 at 2:20 PM, and was asked where wound care would be documented. EI # 11 stated wound care would be located in the nursing assessment on admission and the shift assessment.

During an observation on 2/11/13 at 11:02 AM, EI # 12, RN, took a glucometer to an unsampled patient room and obtained a blood glucose reading. EI # 12 took the glucometer to the nurse station and placed in the charging area. EI # 12 did not clean the monitor prior to placing in the charger. EI # 12 was asked when the monitor was cleaned and EI # 12 stated the monitor was cleaned with "Cavi Wipe" prior to taking to patient room. The Cavi Wipe was not listed as approved for the cleaning of the glucometer and the glucometer should be cleaned after leaving a patient room to prevent cross contamination.




20228


A tour of the Emergency Department (ED) was conducted on 1/16/13 at 1:30 PM. The surveyor reviewed the ED logs for 2013 and requested 10 medical records to review.

During observation of care provided on 1/16/13 from 1:30 PM to 3:00 PM the surveyor observed the following:

1. Employee Identifier (EI) # 8, ED Nurse was observed placing linen in the dirty linen container with a gloved hand. EI # 8 then went back to the patient care area without hand hygiene.

2. EI # 8 then left the patient care area without hand hygiene and began documenting in the computer.

3. EI # 8 was observed obtaining blood via left antecubital space with a butterfly needle without gloves.

4. A step stool was observed in ED room # 101 with a red blood appearance stain.

5. Several rooms were observed being cleaned between patients. When the stretcher in each room was cleaned the staff did not clean under the mattress.

6. During observation of ED room 101 being cleaned between patients, a staff member was observed placing a urinal with approximately 200 cc (cubic centimeters) of urine in the regular trash.

An interview was conducted with EI # 7, ED Director on 1/16/13 at 2:45 PM. EI # 7 stated recognition of 1 of 10 ED records pulled by the surveyor. The surveyor asked which patient it was and the response was PI # 3. The surveyor then asked why he/she recognized PI # 3. EI # 7 stated that the Charge Nurse called him on 1/7/13 to inform EI # 7 of a incidence with PI # 3. EI # 7 stated that PI # 3 sat on the stretcher and a few minutes later realized her clothes were wet from the previous patient's urine. EI # 7 stated that the mattress was not cleaned underneath and the urine from the previous patient was left.



7. PI # 1 was admitted to the facility on 12/24/12 with admitting diagnoses including Cholecystitis, Possible Common Bile Duct Obstruction, Ileus, Hypertension, and Back Pain.


Review of the Operative Note dated 1/15/13 ( which should have been 1/14/13) revealed documentation as follows, "...we debrided the heel all the way down to the bone and bleeding tissue...It was a eschar with some wet and dry gangrene noted. We excised it all the way down to the bone...then the second toe on the right foot had what looked like an infection area over the top of the toe. I was able to debride it all the way down to the bleeding tissue..."

An interview with Employee Identifier ( EI) # 2, Chief Nursing Officer on 1/15/13/at 10:40 AM when the surveyor asked for wound measurements, photo, and description. EI # 2 was unable to locate any documentation of the wound description of any kind. EI # 2 stated there should have been photos on admission, measurements, descriptions of the wound and surrounding tissue.

On 1/16/13 at 7:50 AM the surveyor reviewed the medical record and there was no documentation of wound measurements, a photo, or a description.

The surveyor then requested to see the wound. EI # 2 and EI # 3 , Registered Nurse went to PI # 1's room with gauze and normal saline (NS). EI # 2 removed the dressing from the left heel. There was approximately a 5 cm (centimeter) ring of dried blood on the old dressing. EI # 2 threw the dressing in the regular trash. EI # 2 measured the wound 5 cm long, 4 cm wide, and 1/2 cm deep with blood red tissue. Bone was exposed.

EI # 2 cleansed the wound to the left heel and then covered the wound with gauze moistened with NS with the same pair of gloves used to remove the old dressing. EI # 3 then wrapped the wound to the left heel. EI # 3 then removed the dressing from the left great toe and was waiting for EI # 3 to return with more gauze. The left great toe was dripping blood on to the linen. EI # 3 then placed gauze under the toe to catch the dripping blood. After EI # 3 dressed the left great toe EI # 3 threw the gauze the toe had been dripping on in the regular trash.

EI # 3 then removed the dressing from the right 2nd toe with the same pair of gloves used to remove the dressing from the left great toe. EI # 3 then dressed the left great toe and the right 2nd toe using the same gloves.




Tonya Blankenship, Registered Nurse
Kay Bice, Registered Nurse
Carolyn Andreu, Registered Nurse
Michell Oliver, Registered Nurse
Tereasa Jackson, Registered Nurse
Judy Alexander, Registered Nurse
Cynthia Ball, Registered Nurse