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Based on medical record and policy reviews and interviews it was determined the facility failed to ensure restraint assessments were completed every two hours per policy for 1 of 2 records reviewed. This affected Medical Record (MR) # 11 and had the potential to affect all restrained patients.

Findings include:

Facility Policy: Restraint
Effective date: 10/2002

"Reassessment 3. Medical/Surgical a. The continued need for the use of restraint will be re-assessed and documented every 2 hours."

1. MR # 11 was admitted on 6/12/12 with diagnosis of Basal Cell Carcinoma.

A review of the medical record revealed an order, dated 6/12/12 at 3:52 PM, for soft limb restraints for protection of lines/tubes for 24 hours.

A review of the nurse progress notes for restraint usage, from 6/12/12 to 6/13/12, revealed no documentation of a two hour assessment from 6/12/12 at 4:40 PM to 6/13/12 at 7:00 AM. A review of a nurse note narrative, dated 6/12/12 at 7:00 PM, included, "Restraint untied at this time." There was no further documentation of restraint intervention during this time frame.

An interview on 8/23/12 at 11:30 AM with Employee Identifier # 2, Registered Nurse Manager, confirmed the policy for restraint assessment had not been followed.

Based on medical review, policy and procedures, and an interview with administrative staff it was determined in 2 of 2 medical records reviewed with wounds the nurse failed to:

1. Follow orders for wound care

2. Have orders for wound care provided

3. Document and measure the size and description of the wounds.

This had the potential to affect all patients receiving wound care and did affect Medical Record (MR) # 13 and # 8.

Facility Policy: Wound Care
Policy # GEN W-1

Purpose: To identify potential and/or actual skin problems and provide needed treatment to maximize outcomes.

Policy: Each patient admitted... will receive a physical assessment including the skin. Each adult's skin assessment will be graded according to the Braden score. The following skin care practices are recommended.

Procedure: The following guidelines are recommended for a Braden score of 17 or greater.

Universal Skin Care Practices:
1. Cleanse with perineal cleanser immediately after soiling.
2. Use moisturizing product on skin.
3. Do not massage over bony prominences.
4. Use absorbent underpads for moisture problems.
5. Use barrier ointment on skin exposed to urine, stool or moisture. Reapply after cleansing.
6. Utilize pressure reduction mattress in hospital and long-term care facility as recommended.

The following guidelines will be used for a Braden score of less than 17.

Prevention guidelines for " at risk" hospital patients & long term care residents:
1. Continue Universal skin care practices
2. Bathe with oil-based soap.

When there is an actual skin breakdown, prevention guidelines should continue to be used in addition to the following recommendations.
(The treatment guidelines for skin breakdown continue with definitions of Stage I through IV and the recommended wound cleanser and dressing to be used for each type of pressure area.)

The wound care policy failed to include information related to surgical wounds and failed to include guidelines for wound care provided by physical therapist.

Medical Record Findings:

1. MR # 13 was admitted to the facility on 5/10/12 with diagnoses of Osteomyelitis not otherwise specified, Paraplegia, Methicillin Resistant Staphylococcus Aureus, Streptococcus Infection and Necrotic Infected Foot Ulcers Left Heel.

The physician's admit orders included, "Vancomycin per pharmacy start ASAP (as soon as possible), Cipro 400 mg (milligrams) IV (intravenous) every 12 hours first dose now, change bandages BID (twice a day) and PRN (as needed). Consent for Debridement of foot wound bilaterally..."

The nurse documented on 5/10/12 at 8:00 PM, "Pressure ulcer left ankle, dressing changed, odor foul, appearance reddened, wound length 7.0 cm (centimeter) by wound width 7.0 cm, stage III. Wound topical solution/irrigant- enzymatic irrigant, wound packing type- gauze pads, wound primary dressing type- wet to dry wrapped with Kling.

Left inner heel pressure ulcer-odor foul, appearance reddened, wound length 3.0 cm by wound width 3.0 cm, stage III. Wound topical solution/irrigant- enzymatic irrigant, wound packing type- gauze pads, wound primary dressing type- wet to dry wrapped with Kling.

Left heel pressure ulcer-odor foul, appearance reddened, wound length 3.0 cm by wound width 3.0 cm, stage III. Wound topical solution/irrigant- enzymatic irrigant, wound packing type- gauze pads, wound primary dressing type- wet to dry wrapped with Kling.

Pressure ulcer right anterior ankle- dressing changed, odor foul, appearance reddened, wound length 5.0 cm by wound width 5.0 cm, stage III. Wound topical solution/irrigant- enzymatic irrigant, wound packing type- gauze pads, wound primary dressing type- wet to dry wrapped with Kling.

Pressure ulcer right ankle- dressing changed, odor foul, appearance blackened, wound length 4.0 cm by wound width 4.0 cm, stage III. Wound topical solution/irrigant- enzymatic irrigant, wound packing type- gauze pads, wound primary dressing type- wet to dry wrapped with Kling.

Pressure ulcer right posterior foot - dressing changed, wound drainage amount moderate yellow brown, odor foul, appearance blackened/ reddened, wound length 10.0 cm by wound width 3.0 cm, stage III. Wound topical solution/irrigant- enzymatic irrigant, wound packing type- gauze pads, wound primary dressing type- wet to dry wrapped with Kling.

Pressure ulcer right posterior foot- dressing changed, wound drainage amount moderate yellow brown, odor foul, appearance blackened/ reddened, wound length 10.0 cm by wound width 3.0 cm, stage IV. Wound topical solution/irrigant- enzymatic irrigant, wound packing type- gauze pads, wound primary dressing type- wet to dry wrapped with Kling.

There was no documentation of an order for the wound care provided by the nurse on 5/10/12.

The physician's orders dated 5/11/12 documented, " Status/post debridement left and right foot, whirlpool daily, change dressing daily with Xeroform gauze, superficial wounds pack deep wounds with 1 inch nugauze..."

MR # 13 received whirlpool daily 5/12/12 through 5/15/12 when he was discharged home to continue outpatient whirlpool 2 times a week and continued to receive IV Vancomycin for 6 weeks.

In an interview on 8/23/12 at 11:15 AM, with EI # 1, the Chief Nursing Officer, it was confirmed the nurse did not have orders for the wound care provided 5/10/12.

2. MR # 8 was admitted to the facility on 7/30/12 for elective surgery.

Physician orders dated 7/30/12 documented, "Status post right hemicolectomy/ total abdominal hysterectomy... Change dressing daily with 4 x 4 gauze."

The nurse documented on 8/1/12, "Abdominal dressing dry and intact."

The nurse documented on 8/2/12, "Triple antibiotic ointment applied to incision, covered with dry gauze and secured with tape."

The nurse documented on 8/3/12, "Dressing change to ABD (abdomen), staples in place with scant bloody drainage to old dressing. removed. No redness or signs of infection noted, applied neosporin ointment covered with sterile 4 x 4's, ABD pad and secured with tape."

The nurse documented 8/4/12 at 2:18 PM, "Abdomen incision- dressing changed, wound drainage amount minimal serous, no odor, appearance staples intact,wound packing type- gauze pads, ABD pad."

There was no documentation of an order for the wound to be packed on 8/4/12.

There was no documentation the daily wound care ordered was completed by the nurse on 8/5/12 and 8/6/12.

The physician visited the patient on 8/6/12 and removed two skin clips to lower with midline incision serosanguinous drainage noted and cultured.

The physician's orders for 8/6/12 at 9:10 AM documented, " Abdominal wound culture, pack wound BID (twice a day) with moistened 4 x 4 gauze."

The physician changed the wound care orders on 8/8/12 to Calcium Alginate BID wound care and then on 8/9/12 referred to home health for wound care and pack wound BID with Nugauze.

The nurse failed to document a measurement or appearance of the wound after dehiscence of the area and need for BID packing.

In an interview with EI # 1, the Chief Nursing Officer on 8/23/12 at 10:35 AM, the above information was confirmed.

Based on observations during 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 include:

Refer to the Life Safety Code survey report.

Based on review of the facility policies, directions for use on the Sanizene Cen-Kleen bottle, observations, interviews and review of the whirlpool culture reports, it was determined the facility failed to ensure the staff followed the acceptable standards of practice for cleaning the whirlpool. This had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: Preventive Maintenance and Cleaning
Revised 10/02

"Controls 9.1 Whirlpool cleaning procedures 9.1.1 Clean the whirlpool using routine cleaning procedures. 9.1.2 Cover entire tank surface area with Cen-Kleen using Ferno Healthcare automatic mixer/hand sprayer. 9.1.3 Fill tanks as if giving a routine treatment. 9.1.4 Circulate tank water using agitator turbine for 10 minutes. 9.1.5 Drain and finish cleaning tanks.

9.2 Pathological contamination 9.2.1 Fill contaminated tank with water as if preparing to give a routine treatment. 9.2.2 Add Cen-Kleen as per whirlpool cleaning procedures. 9.2.3 Let water circulate for 30 minutes. 9.2.4 Drain and clean with contact disinfectant. 9.2.5 Report to infection control. 9.2.6 Report to environmental services to perform thorough cleaning of whirlpool area."

Medical Record findings:

1. Medical Record (MR) # 13 was admitted to the facility on 5/10/12 with diagnoses of Osteomyelitis not otherwise specified, Paraplegia, Methicillin Resistant Staphylococcus Aureus, Streptococcus Infection and Necrotic Infected Foot Ulcers Left Heel.

The physicians admit orders included, "Vancomycin per pharmacy start ASAP (as soon as possible), Cipro 400 mg (milligrams) IV (intravenous) every 12 hours first dose now, change bandages BID (twice a day) and PRN (as needed). Consent for Debridement of foot wound bilaterally..."

The physician's orders dated 5/11/12 documented, "Status/post debridement left and right foot, whirlpool daily, change dressing daily with Xeroform gauze, superficial wounds pack deep wounds with 1 inch nugauze..."

MR # 13 received whirlpool daily 5/12/12 through 5/15/12 when he was discharged home to continue outpatient whirlpool 2 times a week and continued to receive IV Vancomycin for 6 weeks.

In an interview with Employee Identifier (EI) # 3, the Registered Physical Therapist on 5/23/12 at 9:30 AM, the surveyor asked if the whirlpool was pathologically contaminated how was it cleaned after use on a patient known to have MRSA. EI # 3 confirmed the whirlpool was not terminally cleaned, it was only cleaned the usual way with cleanser ran through a cycle. The surveyor asked if the whirlpool was cultured on a regular basis and EI # 3 stated, "No."



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A tour of the Rehabilitation Unit was conducted on 8/22/12 at 1:30 PM, with EI # 3. During the unit tour, the surveyor observed two whirlpools. EI # 3 reported one of the whirlpools was an extremity whirlpool and the other was a full body whirlpool. The surveyor asked what the whirlpools were cleaned with. EI # 3 directed the surveyor to a bottle of CEN-KLEEN IV. The surveyor asked how much of the cleaner was used during the whirlpool cleaning. EI # 3 responded " not a set amount-we pour some in there".

The surveyor observed the manufacturers directions which read 2 ounces of CEN-KLEEN IV to 4 gallons of water. The surveyor asked EI # 3 how many gallons of water the extremity whirlpool and the full body whirlpool held. EI # 3 was unable to answer the surveyor. There were no gallon amounts posted on either of the whirlpools to assist the staff in adding the proper amount of CEN-KLEEN IV for cleaning of the whirlpools between use and after pathological contamination.