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Based on observation, staff interview, and medical record review, the facility failed to ensure there was an effective quality assurance and performance improvement (QAPI) program in place. The findings were:

Interview with the administrator, DON, and four additional members of the QAPI team on 9/14/10 at 2:30 PM showed the program did not maintain adequate oversight of areas of deficient practice identified during the survey. These included pain management, preventive skin care and management of skin breakdown, and infection control practices. Inadequate pain management was also identified in the previous survey completed on 3/25/10. Refer to Federal citations A385, A395, and A396 for concerns regarding pain management and management of skin issues. Refer to Federal citations A747 and A749 regarding deficiencies related to infection control practices.

Based on staff interview, medical record review, and review of nursing policies and procedures, it was determined the hospital failed to ensure all nursing requirements were met. There lacked evidence nursing staff provided the necessary assessments, monitoring, and nursing measures to ensure adequate pain management and prevention of skin issues (A395). Evidence demonstrated a lack of complete, accurate assessments and knowledge to interpret the data that was obtained. This resulted in failure to notify the physician of findings which impacted patients ' wellbeing. Evidence indicated that although pain was treated, the treatment was, at times, ineffective, and pain was not controlled at a level acceptable to patients. The program for management of wound and/or skin issues was ineffective in preventing skin breakdown after patients were admitted to the facility. The hospital did not ensure plans of care were modified to address patient needs as they changed and new interventions put in place (A396). The plan for treating skin breakdown for each patient was continued unchanged, and the cause of the ineffectiveness of the established treatment plan was never determined. The combined results of these systems failures resulted in the inability of the hospital to ensure nursing assessments, monitoring and nursing measures were adequately and appropriately provided for all patients and resulted in a determination of immediate jeopardy being called on September 24, 2010 at 12:22 PM.

Based on observation, staff interview, and review of policies and procedures, nationally recognized standards for infection control practices, and the glucometer manufacturer's instructions, the facility failed to successfully develop, implement, and evaluate a hospital-wide infection prevention and control program which met their stated goal: "to minimize the possibility for transmitting infection." Refer to A749 for detailed information related to failure to limit "unprotected exposure to pathogens...transmission of infections associated with procedures...transmission of infections associated with the use of medical equipment, devices, and supplies." The combined results of this system failure resulted in the inability of the facility to ensure a safe environment, identify the risks for infections, and reduce the potential for acquiring an infection for patients, employees, physicians, and visitors.

Based on observation and patient and staff interviews, the facility failed to provide privacy during personal care for 3 of 10 sample patients (#3, #4, #17) observed during the provision of care. The findings were:

1. Observation on 9/13/10 at 3:41 PM showed nursing staff closed the door during the provision of personal care for patient #4. At 3:57 PM respiratory therapist #4 knocked on the door and entered without waiting for permission. The patient's genital area was totally exposed and in full view of the therapist as she walked over and checked the wall oxygen while RNs #7 and #10 completed personal care. The nursing staff made no attempt to cover the patient or instruct the therapist to wait until care was completed. Interview with the patient at 4:10 PM that day revealed s/he was unaware the therapist entered the room. However, the patient stated s/he would have been embarrassed and it "...would have not been OK..." if s/he had known. The patient went on to share another "...very embarrassing..." incident which occurred that morning. The incident happened in the therapy department and involved exposure of his/her genitalia to a member of the opposite sex when staff forgot to pull the curtain at the end of the bed. The patient stated s/he didn't "...want it to ever happen again."

2. On 9/13/10 at 5:43 PM observation showed PCTs #13 and #9 were assisting patient #17 with personal care. The patient was using a bedpan. At 5:46 PM RN #6 knocked on the door, then entered immediately without waiting for permission. The patient's buttocks and perineum were exposed when the door was opened. After disimpacting the patient, the RN left, then returned at 5:53 PM and again knocked but entered without obtaining permission.

3. During an observation on 9/14/10 at 10:30 AM patient #3 required staff assistance to change a disposable brief. The nurse manager, RN #15, used the call light for assistance, and at 10:37 AM, LPN #11 knocked on the door, but entered without obtaining permission. At 10:41 AM, an unidentified staff member opened the door and asked if more assistance was needed. The patient's trousers and brief had been removed and the patient was exposed from the waist down.

4. During an interview on 9/16/10 at 9:37 AM, the nurse manager stated her expectation was that privacy would be provided during care. She stated doors should be closed and staff should knock and wait for permission before entering. She further stated that if no answer was forthcoming, staff should open the door slightly and request/obtain permission before entering.

16678

Based on observation, patient and staff interviews, and review of medical records and policies and procedures, the facility failed to provide adequate supervision and evaluation of the nursing care provided for 5 of 10 sample patients (#3, #4, #7, #14, #17) whose care was observed. In addition, 3 of 13 closed, sample records (#2, #15, #23) lacked evidence that nursing staff completed accurate assessments, correctly interpreted and reported the data, exercised appropriate judgement, complied with orders, and/or provided care that met the patient's needs. This failure resulted in notifying the administrator at 12:22 PM on 9/24/10 that the facility was in immediate jeopardy. The findings were:

A. The physician's history and physical (H & P) dated 8/24/10 showed patient #2 was admitted from an acute care facility on 8/23/10 after a radical neck dissection due to cancer. The physician documented the patient had a complicated post-operative course, which included respiratory failure and acute renal failure requiring dialysis prior to his/her present admission. Review of the medical record for the patient on 9/14/10 showed an assessment related to a change in condition was lacking. Further review showed the record also lacked an assessment and evidence of physician notification related to a fluid imbalance.

1. Evidence related to the patient's change of condition:
a. Medical record review showed a physician's order dated 9/12/10 at 6 AM ordering the patient be transferred to the acute care hospital emergency room "via emergent ambulance." Review of the nursing notes showed the following as the last nursing entry made by RN #16 at 4:23 AM on 9/12/10: "received report on pt [patient] at 2200 [10 PM], no c/o [complaints of] pain or discomfort. pt slept poorly, continues to try to get out of bed without calling for help. no other changes"
b. Further review of the medical record showed no other nursing assessments related to the patient's change in condition or reason for transfer to the acute care hospital. A physician's progress note dictated on 9/12/10 at 7:18 AM recorded the patient had been experiencing respiratory distress since 4 AM without improvement after an inhalation treatment. The patient required emergent transfer to the acute care hospital for this condition. Interview and chart review with the DON on 9/15/10 at 4:34 PM revealed no other assessment information was available.

2. Evidence related to lack of assessment and physician notification for a fluid imbalance:
a. Review of the medical record revealed the aforementioned change in condition experienced by the patient the morning of 9/12/10. It also contained a routine chest x-ray report dated 9/10/10 at 12:40 PM which stated, "Findings most consistent with congestive heart failure. Superimposed pneumonia could be present at either base." Review of intake and output sheets showed the patient consistently consumed and retained fluid as follows:
i. 9/6/10 had 2,750 milliliters (ml) in and 1,575 ml out, for an imbalance of 1,175 ml of retained fluid.
ii. 9/7/10 had 3,220 ml in and 1,750 ml out, for an imbalance of 1,470 ml of retained fluid.
iii. 9/8/10 had 2,670 ml in and 1,500 ml out, for an imbalance of 1,170 ml of retained fluid.
iv. 9/9/10 had 2,995 ml in and 600 ml out, for an imbalance of 2,395 ml of retained fluid.
v. 9/10/10 had 3,060 ml in and 1,890 ml out, for an imbalance of 1,170 ml of retained fluid.
vi. 9/11/10 had 2,910 ml in and 1,175 ml out, for an imbalance of 1,735 ml of retained fluid.
This was a total of 9,115 ml of fluid retained by the patient. Yet, review of the nurses' notes revealed no evidence nursing staff had assessed the patient or notified the physician of the fluid imbalance.
b. Interview and chart review with the DON on 9/15/10 at 4:34 PM revealed staff reviewed each patient's record for care concerns with all acute care transfers out of the facility. The DON stated she could not find evidence the physician had been notified related to the fluid imbalance.
c. Reference: Smith, Duell, Martin, "Clinical Nursing Skills, Basic to Advanced Skills," copyright 2008, "Client's intake and output are maintained within expected parameters of 200 - 300 ml of each other."
d. Reference: Elkin, Perry, Potter, "Nursing Interventions and Clinical Skills, 4th edition," copyright 2007, "Client's are at risk for cardiac and pulmonary complications if fluid overload develops."

B. Record review and observation revealed the scenario described below. Review of the admission Interdisciplinary Screen and Rehab Nursing Assessment showed patient #4 was admitted on 9/6/10 with "wounds, breakdown, or pressure areas" but the documentation only described "...very dry feet..." Further review of the record showed the patient was admitted with an intact surgical incision on the right flank after removal of the kidney. The documentation indicated the incision edges were approximated, no redness or drainage was noted, and steristrips (small strips of adhesive of various lengths and widths used in place of sutures) were present over the incision. According to the first pictures on the wound addendum form, dated 9/9/10, the patient also had three drain sites around the surgical incision. The current treatment listed on the form for sites #1 and #2 was to clean them with normal saline, apply a covaderm dressing, and change it daily or as needed. Treatment for the third site was to leave it open to air and keep it clean and dry. Measurements dated 9/7/10 were indicated on the addendum for the drain sites. A separate wound addendum dated 9/9/10 displayed a picture of an open area on the patient's right groin described as "superficial." A ruler dated 9/8/10 was shown in the picture, and the treatment was "Cleaned & dried, applied gauze to area to keep dry."

Observation of the patient's skin with RNs #7 and #10 on 9/13/10 at 3:41 PM revealed the following: the incision had an open area about 2.5 inches long at the proximal end; an open area about 5/8 of an inch long on the right side of the genitalia with an open, ulcerated strip approximately 1-inch long above it; a red strip approximately 4-inches long on the left inner thigh; an open area approximately 3-inches long in the right groin under the pannus (fat tissue in the abdominal wall) with reddened skin surrounding it and extending approximately a total of 8 inches along the groin; a red bruise approximately 3/4 of an inch wide and 8 inches long on the left buttock; and an excoriated area about 3 inches in diameter on the left posterior inner thigh.

After donning non-sterile gloves on 9/13/10 at 3:41 PM, the RNs were observed to provide care to the patient. Perineal care was completed by RN #7 who cleansed in a back and forth motion over the perineum. During this process, the RN stated the patient's bleeding had slowed considerably. Without removing the gloves, the RN next cleaned the open area on the patient's groin and applied Nystatin (antifungal) powder. Then the RN removed the old dressing from the surgical site, irrigated the wound, and applied a new dressing, all while wearing the same pair of contaminated gloves used with perineal care. Finally, RN #10 squeezed Calazime ointment onto her gloved fingers three separate times, each time touching her gloved fingers to the mouth of the tube. Both RNs applied the ointment to the drain sites and covered them with gauze.

Observation at 5:22 PM that evening showed PCTs #9 and #13 used a mechanical lift to transfer the patient into a wheelchair. During the process, PCT #9 hooked the patient's indwelling urinary catheter bag to the overhead lift bar, thus raising it approximately a foot above the patient's bladder. Dark amber urine ran back up the tube into the patient's bladder. Deficient practice was noted with wound care, perineal and catheter care, and documentation.

1. Deficient practice related to wound care:
a. On 9/15/10 at 3:30 PM the nurse manager stated the dressing to the surgical incision should have been completed using sterile technique. The RNs used a non-sterile technique to accomplish this dressing change. Refer to A749 for further information.
b. Interview with the nurse manager on 9/14/10 at 4:40 PM revealed recommendations from the wound team were not actually orders unless written on the order sheets or the form for wound care orders. On 9/15/10 at 3:30 PM the manager confirmed the treatments recommended on 9/9/10 were not orders, but stated they should have been. The manager stated they were missed during wound rounds. The nurse manager also stated the application of Calazime required an order and confirmed the lack of an order for this patient.
c. Touching the mouth of the tube while squeezing Calazime ointment from the tube was a breach of technique and contaminated the remaining ointment. Refer to A749 for details.
d. Moving from wound to wound while wearing the same pair of gloves was a breach of technique. Refer to A749 for details.

2. Deficient practice related to perineal and catheter care:

a. Perineal care was not completed according to nursing standards of practice. Refer to A749 for detailed information.
b. Raising the catheter bag above the patient's bladder was inappropriate as potentially contaminated urine ran back up the tubing and entered the patient's bladder, thus increasing the possibility for a urinary tract infection. Refer to A749 for more information.

3. Deficient practice related to inaccurate, incomplete documentation:
a. According to the facility's 11/1/07 policy and procedure entitled "Interdisciplinary Wound Prevention Assessment and Treatment," each patient's skin integrity "...will be assessed on admission using the Braden Skin Risk Assessment Tool...For those patients at high risk (score 16 or less), a plan will be initiated and care provided...In addition, every patient's skin integrity will be reassessed every 12 hours ...Skin breakdown will be assessed for appearance, approximation, drainage/exudate, and stage/depth...During the assessment and in any subsequent assessment, any patient may be referred to the interdisciplinary wound treatment team, should it be determined that the patient is at risk for development of a wound..." There was no evidence this patient's skin was thoroughly assessed on admission. Even after additional documentation of skin breakdown on 9/7, 9/8, 9/10, and 9/13/10, and a Braden score ranging from 15 to 18, there was no evidence the patient was seen again by the wound treatment team or that an effective plan was developed and implemented to prevent further skin breakdown. b. During the observation at 3:41 PM, RN #7 stated the open area in the groin was present on admission; review of the admission forms revealed it was not documented until 9/9/10. Further, the ruler in the picture was placed so the numbers were away from the wound, and they were partially covered; it was not possible to accurately determine the length of the wound. However, the open area looked to be smaller (approximately 1.5 inches long) than when observed on 9/13/10.
c. Although the skin issues were documented in the nursing assessments, accurate measurements and descriptions were not included. Further, the dates of the measurements in the pictures on the wound addendums and the dates the addendums were completed did not match; no explanation for this discrepancy was provided.

C. Observation and record review revealed the scenario described below. Observation on 9/13/10 at 1:25 PM showed physical therapist #3 was working on transfers with patient #14. During the transfer to bed, the therapist held the patient's indwelling urinary catheter bag above the level of the bladder, and urine ran back up the tube. After completing the transfer into bed, the patient began to complain of pain and displayed severe facial grimacing when the therapist started exercises to his/her left leg. At that time, a family member stated the patient had not been medicated for pain all day, and the therapist responded that someone was bringing pain medication. At 1:42 PM RN #7 administered acetaminophen (Tylenol) 500 milligram (mg) and asked the patient to rate his/her pain on a scale of 0 to 10 (0 = no pain, 10 = worst pain). The patient stated that pain with movement was 6 to 7 out of 10. When the therapist immediately began the exercises again, the patient became nauseated. When exercising the right leg a few minutes later, the patient complained of pain with the catheter. At 1:52 PM PCT #13 checked the catheter and stated there was a small amount of blood in the disposable brief. Further observation with RN #8 at 2:01 PM and RN #7 at 2:10 PM showed a meatal tear with steristrips coming loose. In addition, there was an abraded area on the glans of the genitalias where a steristrip had been applied. RN #7 cleansed the tear and abrasion and applied Bacitracin and more steristrips. At 2:23 PM physical therapy assistant (PTA) #12 arrived and assisted the patient out of bed for speech therapy. During the process, the patient stated it "... hurts like hell..." to move and again became nauseated. Deficient practice was identified with inadequate pain control, failure to obtain implemented orders, and catheter care.

1. Deficient practice related to inadequate pain control:
a. Review of the admission orders showed the patient could have acetaminophen 500 mg for pain rated at a level of 1 or 2. This patient rated his/her pain at 6 to 7. Review of the physician's progress notes showed several instances of documentation that pain was uncontrolled.
b. Despite the patient's continued complaints of severe pain and bouts of nausea, the therapist continued with the exercises, and the PTA assisted the patient from the bed. Neither allowed time for the medication to be absorbed and become effective.

2. Deficient practice related to lack of orders:
Although the physician was informed of the patient's meatal tear on 9/5/10, steristrips were not ordered. Further, evidence was lacking that the physician was notified of the abrasion on the patient's genitalia where a steristrip had been applied. On 9/16/10 at 1:50 PM the nurse manager confirmed steristrips were not ordered.

3. Deficient practice related to catheter care:
Holding the catheter bag above the bladder was not appropriate as dark amber urine streaked with blood drained back into the patient's bladder, increasing the potential for a urinary tract infection. Refer to A749 for details.

D. Record review and observation revealed the scenario described below. According to the admission assessment, patient #3 was admitted on 8/25/10 with a urinary tract infection (UTI). Review of documentation of the patient's skin that evening showed "slight irritation noted to buttocks, applied Calazime." The documentation showed an indwelling urinary catheter was in place. Bowel continence was not assessed. Review of the 7:05 AM assessment on 8/26/10 showed the patient was incontinent of bowel and had "slightly red buttocks", but the assessment that evening at 7:39 PM showed the patient had no skin breakdown. The response for potential breakdown was documented as "Patient specific bowel management." Review of the remaining assessments showed no evidence of skin breakdown until 9/8/10 at 6:45 AM when the patient was described as having "...slight excoriation...on inner buttocks after BM, applying cream to site." From 7:05 PM that evening until 7 AM on 9/10/10, staff documented the patient had no skin breakdown. On 9/10/10 the description was of "...Small red bumps and redness noted throughout...Patient grimaced & reported pain..." That evening, the documentation described a "...red rash to buttocks..." Review of the remaining documentation through 9/14/10 showed staff continued to document a "rash" to the resident's buttocks.

Observation on 9/14/10 at 10:30 AM revealed staff answered the call light and a family member stated the patient's incontinence brief needed to be changed. The patient had an indwelling urinary catheter and had been incontinent of bowel with excoriated skin surrounding the anus and on both buttocks. The excoriated area was in a circular pattern extending approximately three inches in diameter from the anus. The skin was dry and flaking with scabs in some areas. After completion of perinel care, the LPN applied Calazime ointment to the perineal area, rubbing from the anus towards the urethra. Deficient practice was identified with perineal care and documentation.

1. Deficient practice related to perineal care:
a. Calazime ointment was provided inappropriately after perineal care. Refer to A749 for details.
b. Despite receiving appropriate treatment for a UTI present on admission, review of laboratory results showed the patient developed another UTI on 9/7/10. The organism present in both instances was Eschericia coli, a bacterium normally present in the bowel, but which causes infections when introduced into the urinary tract.

2. Deficient practice related to documentation:
a. Staff failed to consistently provide accurate descriptions of the patient's skin breakdown which included measurements, color, texture, and drainage; refer to the policy and procedure referenced in 1.c. above. In addition, the effectiveness of treatment was not documented.
b. Responses for skin integrity were listed on the assessments as "...Speciality bed, Hydration management, Moisture management, Braden protocol." Interview with the nurse manager on 9/14/10 at 6 PM revealed the Braden protocol was initiated for patients who scored 16 and under. The manager described the protocol as consisting of checking and changing a patient's brief every one to two hours, turning a patient every two hours or as needed, increasing nutrition, providing a pressure relieving mattress, keeping elbows and heels off the bed with movement, and use of a pull sheet to lift/move patients. Even though these interventions were documented, the manager had no answer as to why the patient kept developing skin breakdown if the program was consistently implemented as described.

E. Record review and observation revealed the scenario described below. Medical record review showed patient #17 was admitted on 8/30/10, and the history and physical completed that day documented the patient had stage I to II pressure ulcers on the coccyx and in the pannus of the left gluteal area. Nursing was to be involved with bowel and bladder management and DVT (deep vein thrombosis) prevention. Review of orders dated 8/31/10 showed the patient was to wear TED (thrombo embolic deterrant) hose daily. Further review showed the order was repeated on 9/8/10 with the notation that this was the second request.

Observation on 9/13/10 at 5:43 PM revealed the patient was having difficulty expelling hard feces. The patient stated s/he was on a softener, but was on medications that caused constipation and the softener "wasn't working." After being manually disimpacted at 5:46 PM by RN #6, the patient was given a suppository and the remainder of the fecal material was later expelled. During the observation, the patient stated s/he had not had a bowel movement for three days. Immediately after the observation the RN confirmed the fecal impaction and stated the fecal matter was "...like glued together rocks..." The following concerns related to nursing care and documentation were identified:

1. The patient was not wearing TED hose during the observation on 9/13/10. Interview with the nurse manager on 9/16/10 at 1:50 PM revealed she was unable to explain why the order had to be repeated on 9/8/10 or why the patient was not wearing them on 9/13/10.

2. Review of the 9/13/10 interdisciplinary progress notes confirmed the patient had not had a bowel movement for three days. Review of the orders showed the patient was on Miralax (laxative) twice daily and, according to the medication administration record (MAR), received Colace (softener) at 5 AM on 9/13/10. However, review of the MAR for 9/14/10 showed the bowel program had not been altered due to the patient's fecal impaction. On 9/16/10 at 2:15 PM the nurse manager stated the patient had a history of constipation and did not have a bowel movement on 9/14/10. She confirmed the bowel program was not changed until 9/15/10.

3. Review of the documentation related to the patient's skin breakdown showed it was not consistently documented as per the policy and procedure cited in B. 3. a. above.

F. Review of the physician's admission H & P performed on 8/23/10 for patient #7 showed s/he was admitted with diagnoses including a past stroke in January 2010 and a new stroke in August 2010. Review of the Interdisciplinary screen and rehab nursing assessment, dated 8/23/10 at 9:30 AM, showed the patient had a quarter size red area to the top of the right buttock near the coccyx. Review of the wound team notes from 8/23/10 showed there was a two centimeter (cm) by two cm area, documented as a Stage I wound that was bright red and possibly from pressure or shearing. Review of the 8/23/10 wound team assessment showed a recommendation by the wound team to apply Calazime cream twice daily and PRN (as needed). Review of the 8/28/10 nursing notes written at 3:50 AM showed the physician was notified of the excoriation by means of a communication board five days after the skin breakdown was identified. Interview with the nurse manager on 9/14/10 at 4:40 PM revealed recommendations from the wound team were not actually orders unless written on the order sheets. Review of 8/28/10 physician's orders written at 2:10 PM showed, that once he was aware of the patient's skin condition, he wrote an order to apply Calazime cream to the rash on the patient's buttocks twice daily. Because of the delay in physician notification, review of the 8/23 through 8/27/10 shift nursing notes and MARs showed no evidence Calazime was applied as recommended for the first four days. Review of the 9/3/10 wound team assessment showed there was no improvement in the patient's skin condition which was "very red with small blisters or bumps."

G. Review of the medical record for patient #15 showed s/he was admitted on 2/6/09 without any skin issues. Review of the admission nursing notes, dated 2/15/09 and timed at 6:30 AM, showed the patient had occasional stress incontinence but was mostly continent of urine. Review of the 2/12/09 nursing shift notes written at 6:30 AM showed the patient's groin was reddened. Review of the remaining nursing shift notes through 2/17/09 showed the patient's groin continued to be reddened despite applying a skin repair cream. Review of the medical record showed no evidence other interventions were attempted to relieve the excoriation of the groin and perineal area for this patient. Interview with the DON at 1:30 PM on 9/16/10 revealed she was unsure why no alternate treatment was attempted to address the patient's excoriation.

Further review of the 2/7/09 H & P showed the patient was admitted with diagnoses including status post total left hip arthroplasty and wound infection. Further review showed the patient's chief complaint upon admission was left hip pain. Review of the medical record revealed the following concerns with pain management:

1. Review of the nursing notes on the following dates and times revealed the patient was administered pain medication for left hip pain with no evidence of a re-assessment being performed within one hour afterwards to determine the effectiveness of the medication: 2/12/09 at 6:30 AM, 2/12/09 at 8 PM (pain was described as 8 on a scale of 0-10 [8/10]), 2/13/09 at 7:15 AM, 2/13/09 at 7:30 PM (5/10), 2/16/09 at 6:30 AM, 2/17/09 at 6:45 AM and 6:59 PM.

2. Review of the 2/18/09 nursing notes written at 6:30 AM showed the patient complained of pain. Review of the MAR PRN intervention form for that date showed the patient was administered two Norco tablets at 7:40 AM for pain rated 9/10. Continued review of the form showed the patient was re-assessed at 8:30 AM to determine the effectiveness of the pain medication, and it was rated at 8/10. Review of the medical record revealed no further interventions were attempted to provide relief from pain still rated at 8/10. On the same day (2/18/09) at 12:15 PM the patient again had pain rated at 9/10 and was given two Norco tablets. At 1:15 PM the patient's pain was re-assessed and was only down to 7/10. Again, review of the medical record showed no further measures were provided to make the patient comfortable.

3. Review of the 2/18/09 nursing shift notes written at 7 AM showed the patient said his/her pain was not controlled. Review of the occupational therapy (OT) daily notes dated 2/12/09 written at 11:14 AM showed the patient required rest breaks to decrease pain during therapy even though s/he had received pain medication at breakfast. Review of the 2/12/09 physical therapy (PT) daily notes written at 12:25 PM showed the patient reported a pain rating of 9/10 in the left leg and noted the patient "reported [his/her] meds are not helping." Review of the 2/12/09 timed at 3:21 PM nursing notes showed the patient complained of "increased leg pain." Further review of these notes revealed the physician was notified of the increase in pain and ordered a routine pain medication (Oxycontin). However, review of the 2/13/09 nursing notes written at 5:06 AM showed the patient was reluctant to ambulate to the bathroom because of the pain in his/her leg. Review of the 2/16/09 PT notes written at 3:15 PM showed the patient reported his/her hip pain was 7/10 even with pain medications. Review of the 2/16/09 OT daily notes written at 4:10 PM showed the patient "continues to require frequent rest breaks throughout tx [treatment] due to increased pain and fatigue."

4. Interview with the DON on 9/16/10 at 1:30 PM revealed pain should be re-assessed within one hour to evaluate whether the patient's pain was relieved by the medication. She further stated the hospital did not have a specific policy on pain management; she said it was included in the re-assessment policy.

H. Review of the closed medical record showed patient #23 was admitted on 10/22/09, and documentation at 8:29 PM that evening showed the patient had skin breakdown on the coccyx. It was described as "...dry/flaking skin and is pink. Healed pressure wound..." No other skin issues were documented at that time. However, review of the wound addendum forms showed the patient developed skin breakdown around the colostomy site, the elbow, the left foot, and the groin and genitalia while in the facility. The documentation of this breakdown ranged from admission on 10/22/09 through 11/4/09. The facility was unable to provide an explanation as to why the skin breakdown occurred if the wound care program was implemented appropriately.






18512

Based on observation, medical record review, patient and staff interview, and review of policies and procedures, the facility failed to ensure care plans were developed and/or revised to meet the needs of 7 of 30 sample patients (#3, #4, #7, #14, #15, #17). The findings were:

1. According to the admission forms, patient #3 was admitted on 8/25/10. Observation on 9/14/10 at 10:30 AM revealed the patient had an indwelling urinary catheter in place and was incontinent of bowel. Review of the initial care plan and the updates through 9/14/10 showed these issues were not addressed. Interview with RN #5 on 9/14/10 at 1:25 PM confirmed these issues were not included on the care plan. However, on 9/14/10 at 5:45 PM the nurse manager stated the information was included on the kardex. Review of the kardex provided the information that the patient had a catheter placed on 8/19/10; the intervention for bowel incontinence was "... Briefs..."

2. Review of the 9/6/10 admission information showed patient #4 was admitted with a closed right flank incision and three drain sites. On 9/13/10 at 3:41 PM, RN #7 stated the patient was also admitted with an open area in the right groin. Observation at the time of this interview revealed the patient had several other wounds and injuries. Refer to A0395 for detailed information. Review of the initial and current care plans revealed effective interventions were not delineated to promote healing and prevent further injury.

3. Observation on 9/13/10 at 2:01 PM with RN #8 showed patient #14 had a tear and an abrasion on the genitalia. Review of the kardex and care plan dated 9/7/10 showed these issues were not addressed. Interview with the nurse manager on 9/16/10 at 1:50 PM revealed the tear occurred on 9/5/10.

4. During an observation on 9/13/10 at 5:46 PM RN #6 manually removed fecal material for patient #17. Immediately after the observation the RN confirmed the patient had a fecal impaction. Review of the care plan on 9/14/10 showed this issue had not been addressed. Further review of the medical record showed TED (thrombo embolic deterrant) hose were ordered on 8/31/10 and re-ordered as a second request on 9/8/10. Review of the initial care plan showed this order was not included. Refer to A0395 for additional information.

5. Review of the initial care plan for patient #7 showed skin integrity was identified as a problem with a goal that skin would remain intact without evidence of breakdown, rash, infection or pruritus. Interventions included the following: perform and score the Braden assessment every 24 hours, inspect skin every shift and as needed, use pressure reduction surfaces for wheelchair seating, monitor bony prominences, use lift/draw sheet to prevent friction while moving the patient in bed, and keep the skin free of urine and/or feces with cleansing immediately after incontinence. The following concerns were identified:
a. While the August and September 2010 MARs showed the patient had Calazime cream applied twice daily after the physician ordered the cream on 8/28/10, review of the nursing shift notes showed no evidence the Calazime cream was applied after each episode of bowel incontinence. According to the 8/28/10 through 8/31/10 and 9/1 through 9/13/10 MARs, the Calazime cream was applied at 9 AM and 9 PM daily. However, review of the daily flowsheets showed the patient was incontinent of feces without evidence the cream was applied on 8/24/10 at 6 AM and 8 PM; on 8/25/10 at 8 PM; on 8/26/10 at 1 AM, 7 AM, 2 PM, 4 PM, 6 PM, 7 PM, 8 PM, 10 PM and 11 PM; on 8/27/10 at 3 AM, 7AM, 8 AM, 10 PM, 11 PM, and midnight; on 8/28/10 at 4 AM, 7 AM, 4 PM, and 8 PM; on 8/29/10 at 10 AM and 1 PM; on 8/30/10 at 3 AM; on 9/3/10 at 2 PM, and 4 PM; on 9/5/10 at 10 AM and 3 PM; on 9/6/10 at 5 AM; on 9/8/10 at 12 noon; on 9/9/10 at 1 PM and 4 PM; on 9/11/10 at 7 AM, 10 AM, and 3 PM; on 9/12/10 at 3 AM, 6 AM, 1 PM, and 8 PM; on 9/13/10 at 1 PM and 4 PM; and on 9/14/10 at 2 AM.
b. Review of the hospital policy and procedure on wound prevention, assessment and treatment, effective 11/1/07, page 2 described a patient with a Stage I sore as being "at risk" for skin breakdown. Page 5 of the policy showed Calazime Protectant Paste was recommended after each incontinence episode for prevention of skin breakdown. Review of the daily flowsheet treatment record showed the patient was frequently incontinent of bowel. However, review of the daily flowsheets showed no evidence the Calazime cream was applied after each incontinence episode. Refer to Federal citation A395 for details in regard to not following the care plan and hospital policy.
c. Review of the case conference care plan updates on 9/1/10 showed the plan did not address the patient's skin issues at all. Review of the 9/8/10 case conference care plan update also showed the only intervention was to "monitor." Review of the entire medical record showed no attempt to change treatment from the Calazime cream to another product despite the fact it did not heal the excoriation (based on the nursing notes). In addition, interview with the patient on 9/16/10 at 10:30 AM revealed the Calazime cream hurt and "burned" him/her. Interview with the DON on 9/16/10 at 10:45 AM revealed this was the first time she was aware the Calazime "burned" the patient. She also said she had talked with the nurse on the unit that morning and a new skin repair cream was scheduled to start on 9/16/10 (after the surveyor asked about the continued excoriation despite treatment with Calazime).

6. Review of the admission documents for patient #10 showed s/he was admitted after sustaining a fall with subdural hematoma which required surgical craniotomy. Review of the 9/10/10 admission care plan showed pain was not identified as a problem. Review of the 9/15/10 case conference and care plan showed staff did identify pain as a problem and identified approaches for pain relief. Refer to Federal citation A395 for details regarding the failure to ensure staff followed the care plan for pain management for this patient.

7. Review of the 2/7/09 physician's history and physical for patient #15 showed s/he was admitted to hospital on 2/6/09 with diagnoses including status post total left hip arthroplasty and wound infection. Further review showed the patient's chief complaint upon admission was left hip pain. Review of the 2/7/09 initial care plan showed pain was identified as a problem; however, there were no goals or interventions developed to manage the patient's pain. Review of the 2/10/09 case conference and care plan review/update showed an intervention to offer other means of pain control to the patient such as heat, ice, and/or elevating the affected leg. Refer to Federal citation A395 for additional information on staff not following the care plan for this patient. Review of the 2/17/09 case conference and care plan review/update showed pain was impeding the patient's progress and was a barrier to his/her discharge. No new interventions were developed.






























18512

16678

Based on observation, patient and staff interview, and review of medical records and policies and procedures, the facility failed to ensure complete and accurate documentation for 4 of 10 open sample patients (#3, #4, #14, #17,) and 2 closed sample patients (#2, #23) whose records were reviewed. The findings were:

Refer to A0395 for detailed information related to documentation issues for patients #2, #3, #4, #14, #17, and #23.

Based on observation, staff interview, and review of policies and procedures, nationally recognized standards for infection control practices, and the glucometer manufacturer's instructions, the facility failed to successfully develop, implement, and evaluate a hospital-wide infection prevention and control program for 6 of 10 sample patients (#3, #4, #9, #12, #14, #17) whose care was observed. The findings were:

According to the facility's policy and procedure entitled "Infection Prevention & Control Plan", effective date of 11/1/07 and last revised on 1/10, the purpose of the infection control program "...is to provide a safe environment..." for everyone who enters the facility. The goal of the program is "...to minimize the possibility for transmitting infection..." by limiting "...unprotected exposure to pathogens...transmission of infections associated with procedures...transmission of infections associated with the use of medical equipment, devices, and supplies." The program failed to accomplish this goal as staff provided inappropriate wound care, improper perineal and indwelling urinary catheter care, reused contaminated supplies, failed to clean and disinfect equipment used for more than one patient, and failed to change gloves when indicated.

1. Concerns regarding wound care:
a. During an observation on 9/13/10 at 3:41 PM RN #7 donned non-sterile gloves and provided perineal care for patient #4. Without removing the gloves, the RN next cleaned the open area on the patient's groin and applied Nystatin (antifungal) powder. Then the RN removed the dressing from the patient's open surgical incision. While still wearing the same contaminated gloves, the RN picked up the syringe of normal saline, which had been placed on the overbed table and then on the bed, inserted it into the opened package of gauze, and injected saline into the package, thus contaminating the gauze. The RN then used the saline to irrigate the wound before packing it with the contaminated gauze. RN #10 squeezed Calazime ointment onto her gloved fingers three separate times, each time touching her gloved fingers to the opening of the tube. While wearing the same gloves, both RNs applied the ointment to the drain sites and covered them with gauze. The following deficient practice was noted:
i. Interview with the nurse manager on 9/15/10 at 3:30 PM revealed the dressing to the incision should have been completed using sterile technique. On 9/16/10 at 8:16 AM the DON presented Lippincott's "Nursing Procedures," fifth edition, published in 2009 by Lippincott Williams & Wilkins and stated it was the manual used for procedures.
ii. Review of pages 165 through 167 of that manual revealed sterile technique was to be used for any procedure that required "...the absence of microorganisms." This was further defined to include "...contact with nonintact skin resulting from trauma or surgery." The listed equipment included sterile gloves, solutions, gauze, and any other supplies used during the procedure.
b. Review of the medical record for patient #12 showed s/he was on contact isolation precautions for MRSA. Observation on 9/13/10 at 4:15 PM showed RN #8 removed a dressing from the patient's right heel, which according to the medical record, was a stage III pressure ulcer. Continued observation after the soiled dressing was removed showed the RN picked up the wheelchair leg from the floor and moved it next to the wall. Then the RN handled a white belt that was saturated in multiple areas with a brown substance, and a few chunks of a brownish colored substance. The RN moved the belt across the surface of the bed. Finally, the RN placed a new, clean dressing on the patient's heel while wearing the same soiled gloves.
c. Review of the "Guideline for Hand Hygiene in Health-Care Settings" finalized by the Centers for Disease Control and Prevention (CDC) on October 25, 2002 / Vol. 51 / No. RR-16 showed hands should be decontaminated "...after contact with body fluids...and wound dressings if hands are not visibly soiled... Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care...". Review of items listed under "Other Aspects of Hand Hygiene" showed "...Change gloves during patient care if moving from a contaminated body site to a clean body site..."

2. Concerns regarding perineal and catheter care:
a. At 3:41 PM on 9/13/10 RN #7 was observed providing perineal care to patient #4. During this procedure the RN cleansed the perineum in a back and forth manner, from the anal area to the urethra, using the same area of the cloth each time. Observation at 5:22 PM that evening showed PCTs #9 and #13 used a mechanical lift to transfer the patient into a wheelchair. During the process, PCT #9 hooked the patient's indwelling urinary catheter bag to the overhead lift bar, thus positioning it approximately a foot above the patient's bladder. Dark amber urine ran back up the tube into the patient's bladder.
b. Observation on 9/14/10 at 10:30 AM revealed patient #3 had an indwelling urinary catheter and had been incontinent of feces. RN #15 and LPN #11 provided perineal care before the LPN applied Calazime ointment to the perineal area. However, the LPN applied it from the anus towards the urethra.
c. On 9/13/10 at 1:25 PM, observation showed physical therapist #3 was assisting patient #14 to transfer from the wheelchair to bed. During the transfer, the therapist held the patient's indwelling urinary catheter bag above the level of the bladder, and dark amber urine with streaks of blood drained back up the tubing into the patient's bladder.
d. According to the reference used as the facility's procedure manual, Lippincott's "Nursing Procedures" fifth edition, 2009, catheter drainage bags should be kept below the level of the bladder at all times. Further review of that manual revealed perineal care should only be provided from front to back "...to prevent intestinal organisms from contaminating the urethra..."

3. As related to reuse of contaminated supplies:
a. On 9/13/10 at 3:41 after completing perineal care, RNs #7 and #10 applied Calazime ointment to the drainage sites of patient #4. Without changing gloves, RN #10 squeezed ointment from the tube three different times, each time touching her contaminated gloves to the opening of the tube. This technique contaminated the ointment remaining in the tube which was then applied to a different area of the body.
b. Observation on 9/14/10 at 10:30 AM revealed patient #3 had an indwelling urinary catheter and was incontinent of bowel. After the completion of perineal care, and while wearing the same gloves, LPN #11 squeezed Calazime ointment from a tube, touching the opening of the tube in the process. This technique contaminated the remaining ointment, but the tube was capped for later use.

4. As related to failure to clean and disinfect equipment used for more than one patient:
On 9/13/10 at 4:22 PM RN #10 was observed while completing a fingerstick blood sugar test for patient #4. The RN placed the glucometer on the bed during this procedure. Without cleaning the glucometer, the RN then performed the test for patient #17 at 4:32 PM. During an interview with the infection control practitioner (ICP) and DON on 9/16/10 at 10:45 AM, the ICP stated the glucometer was only cleaned once per shift unless it had been in an isolation room. When asked if this was the current recommendation from the CDC, the ICP did not know. After reviewing information from the CDC, the ICP reported at 1:05 PM that day that the glucometer should be cleaned and disinfected before being reused for another patient. Review of the manufacturer's instructions provided information on appropriate cleaning and disinfecting solutions. Review of the CDC information entitled "Recommended Infection-Control and Safe Injection Practices to Prevent Patient-to-Patient Transmission of Bloodborne Pathogens" revealed ",,,Glucometers should be assigned to individual patients. If a glucometer that has been used for one patient must be reused for another patient, the device must be cleaned and disinfected..."

5. As related to failure to change gloves when indicated:
a. Review of the medical record for patient #9 showed s/he was on contact precautions for VRE (vancomycin resistant enterococci) and MRSA. Observation on 9/13/10 at 3:20 PM showed RN #10 cleaned off the overbed table for this patient and placed the used and soiled drinking cup and napkin into the trash can. Observation revealed the RN used her gloved hands to lift the top of the trash can lid, instead of the foot pedal. The RN then pushed the gowns and gloves that were already in the trash can down further to make room for the drinking cup and napkin. After discarding the trash, the RN opened a cheese stick, crackers and a milk carton with the same soiled gloves used to push down the trash. The patient was observed to drink the milk from the spout of the carton where the RN had touched it with soiled gloves. Interview with the RN on 9/16/10 at 8:45 AM revealed she should have changed her gloves prior to touching and opening the snack foods for the patient.
b. During an observation on 9/13/10 at 3:41 PM RN #7 donned non-sterile gloves and provided perineal care for patient #4. Without removing the gloves, the RN next cleaned the open area on the patient's groin and applied Nystatin (antifungal) powder. Then the RN removed the dressing from the patient's open surgical incision. While still wearing the same contaminated gloves, the RN picked up the syringe of normal saline, which had been placed on the overbed table and then on the bed, inserted it into the opened package of gauze, and injected saline into the package, thus contaminating the gauze. The RN then used the saline to irrigate the wound before packing it with the contaminated gauze. RN #10 squeezed Calazime ointment onto her gloved fingers three separate times, each time touching her gloved fingers to the opening of the tube. While wearing the same gloves, both RNs applied the ointment to the drain sites and covered them with gauze. The following deficient practice was noted:
i. Interview with the nurse manager on 9/15/10 at 3:30 PM revealed the dressing to the incision should have been completed using sterile technique. On 9/16/10 at 8:16 AM the DON presented Lippincott's "Nursing Procedures," fifth edition, published in 2009 by Lippincott Williams & Wilkins and stated it was the manual used for procedures.
ii. Review of pages 165 through 167 of that manual revealed sterile technique was to be used for any procedure that required "...the absence of microorganisms." This was further defined to include "...contact with nonintact skin resulting from trauma or surgery." The listed equipment included sterile gloves, solutions, gauze, and any other supplies used during the procedure.
c. Review of the medical record for patient #12 showed s/he was on contact isolation precautions for MRSA. Observation on 9/13/10 at 4:15 PM showed RN #8 removed a dressing from the patient's right heel, which according to the medical record, was a stage III pressure ulcer. Continued observation after the soiled dressing was removed showed the RN picked up the wheelchair leg from the floor and moved it next to the wall. Then the RN handled a white belt that was saturated in multiple areas with a brown substance, and a few chunks of a brownish colored substance. The RN moved the belt across the surface of the bed. Finally, the RN placed a new, clean dressing on the patient's heel while wearing the same soiled gloves.
d.Review of the "Guideline for Hand Hygiene in Health-Care Settings" finalized by the Centers for Disease Control and Prevention (CDC) on October 25, 2002 / Vol. 51 / No. RR-16 showed hands should be decontaminated "...after contact with body fluids...and wound dressings if hands are not visibly soiled... Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care...". Review of items listed under "Other Aspects of Hand Hygiene" showed "...Change gloves during patient care if moving from a contaminated body site to a clean body site..."


6. During an interview on 9/16/10 at 10:45 AM, the ICP stated she did not visually monitor dressing changes, perineal and catheter care, or use of gloves. Although she was tracking these issues, she stated monitoring consisted of review of documentation to ensure the care was provided. She stated she was not monitoring to see if the care was provided correctly.






























18512

Based on observation, staff interview and medical record review, the hospital failed to ensure the written rehabilitation dysphagia precautions were followed for 1 (#7) of 10 sample patients observed. The findings were:

Review of the 8/23/10 physician's admission history and physical for patient #7 showed s/he had diagnoses including stroke and dysphagia (difficulty swallowing). The following concerns were identified:
a. Review of the 9/13/10 cardex showed the patient should be reminded to tuck his/her chin when swallowing because of his/her dysphagia. Observation of the evening meal on 9/13/10 from 5:12 PM until 5:43 PM revealed the patient was not cued at any time to tuck his/her chin when swallowing. Interview at 6 PM that evening with the respiratory therapist who was observing the diner's club patients that evening revealed she was unaware of the patient's need for tucking his/her chin when swallowing. Interview with the nurse manager on 9/14/10 at 6 PM revealed the cardex was updated every day and incorporated the patient's needs for that day. She said the cardex contained the most accurate instructions. Observation showed the patient was not reminded to tuck his/her chin at any time during the 31 minute meal observation. Observation revealed that, after drinking a beverage, the patient coughed and tried to catch his/her breath at 5:15 PM, 5:16 PM, 5:32 PM and 5:37 PM.
b. Review of the initial 8/23/10 care plan showed the following interventions for the patient's swallowing disorder: Supervise meals and provide cues for swallowing techniques as indicated by patient functional limitations including: alternating sips and bites, effortful swallow, etc. Also included was to encourage adequate nutritional intake orally utilizing swallowing techniques. Another interventions was for supervision of all oral intake. Review of the rehabilitation dysphagia precautions for the patient located in a diner's club book in the small dining room closet on 9/13/10 showed the patient required 1:1 supervision and nectar thickened liquids. Observation of the evening meal on 9/13/10 from 5:12 PM until 5:43 PM revealed the patient did not receive 1:1 supervision. Observation showed one respiratory therapist was in the dining room to supervise three patients. Interview with the DON on 9/14/10 at 10:45 AM revealed 1:1 supervision meant a staff member sat with the patient at all times and focused on that patient only. Interview with the staff member in the room during the observation at 6 PM revealed she was just to "be there and kind of watch" but was not providing 1:1 supervision for this patient.
c. On 9/13/10 observation at showed the speech therapist gave the patient a regular (not thickened) root beer to drink at 5:30 PM. Interview with the rehabilitation director (the speech therapist was unavailable) on 9/14/10 at 10:45 AM revealed the speech therapist was trialing carbonated beverages, but had not yet determined whether or not they were safe enough to warrant updating the care plan. Observation revealed, however, the speech therapist did not stay in the dining room to observe the patient drink the unthickened beverage to ensure his/her safety; she was in and out and caring for other patients at the same time. Interview with the rehabilitation therapy director (the speech therapist was unavailable) on 9/14/10 at 10:45 AM revealed the dysphagia care plan was not accurate in the diner's club book. The care plan was updated later that day after the surveyor discussed the inconsistency of the dysphagia interventions and plans were identified for this patient.