HospitalInspections.org

Based on review of medical records (MR), policy, and interview it was determined the skilled nurse failed to measure the wounds during wound care and dressing change per facility policy.

This affected MR # 33, 1 of 1 patient with wound observations and had the potential to affect all patients served in this facility with wounds.

Findings include:

Facility Policy: Skin Assessment, and Pressure Ulcer Prevention and Treatment Guidelines
Effective date: 01/01/2016

Purpose:
To establish guidelines for skin assessment, documentation, and pressure ulcer prevention and treatment.

General Information:

4. May consult Wound and Ostomy for open wounds to include but not limited to diabetic ulcers, pressure ulcers, fistulas, and venous stasis.

5. The Wound and Ostomy nurse should measure wounds at time of consult. The wound should be measured with in the next week or on subsequent visits as indicated by patient condition ...

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Wound Documentation

Location
Measurements - Length X (by) Width X Depth
Tunneling - channels extending from the central injury into the surrounding tissue, such as muscle and skin.
Undermining - dead space under wound edge.
...

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1. MR # 33 was admitted to the facility on 8/13/17 with diagnoses including Abcess of Right Knee and Right Forearm.

ON 8/16/17 the surveyor requested all orders and documentation for MR # 33's wound care from the time of hospitalization to current date. The surveyor was provided the following wound care orders:

Review of the Physician Orders dated 8/15/17 at 7:36 AM revealed: "...Daily dressing change to right knee and elbow, change Iodoform packing with dressing change, continue knee immobilizer to right knee, perform skin check twice daily."

Review of the Physician Orders dated 8/16/17 at 12:09 PM revealed: "...Daily dressing change to right knee and elbow. Change Iodoform packing with dressing change. Place 4 X 4 gauze and paper tape to cover wound on right arm and cover wound on right knee with 4 X 4 gauze and ace wrap. Continue knee immobilizer to right knee, perform skin check twice daily."

An observation of wound care with EI (Employee Identifier) # 8, RN (Registered Nurse) on 8/16/17 at 1:12 PM revealed the patient had two wounds; one wound on the anterior aspect of the right knee and one wound on the right forearm.

The surveyor observed EI # 8 remove the old dressing (ace bandage wrap, 4 X 4 gauze, and Iodoform strip packing) from the patient's right knee. EI # 8 measured the tunneling of the wound and packed the right knee with an Iodoform strip. EI # 8 placed several 4 X 4 gauze over the wound site, wrapped the knee with an ace bandage, and placed an immobilizer on the patient's right leg. EI # 8 failed to measure and document the patient's wound to include length, width, and depth per policy.

EI # 8 removed an old dressing (gauze, Iodoform strip, and paper tape) from the patient's right forearm at 1:25 PM. There was no order for placing 4 X 4 gauze and paper tape over the patient's right forearm until 8/16/17 and the last documented wound care was on 8/15/17 at 4:22 PM.

Further observation revealed EI # 8 measured the tunneling of the right forearm wound and packed the wound with a clean Iodoform strip. EI # 8 placed several 4 X 4 gauze over the wound site, and secured gauze with paper tape. EI # 8 failed to measure and document the patient's wound to include length, width, and depth per policy..

The surveyor asked EI # 8, what were the wound measurements for the patient's knee and forearm? EI # 8 replied, "The right knee was 1 inch tunneling and the right elbow was a 1/2 (half) inch tunneling." EI # 8 did not assess, measure, and document the patient's wounds to include length, width, and depth per policy.

On 8/17/17 at 10:30 AM the surveyor was provided Nursing notes from 8/13/17 through 8/16/17. There was no documentation of wound measurements in the medical record.

An interview was conducted on 8/16/17 at 1:30 PM with EI # 12, RN, 3-North - Nurse Manager, who confirmed the above findings.

Based on review of facility policy, medical record (MR) and interview, it was determined staff failed to follow the facility policy for the management and destruction of home medications in 1 of 1 patient death records that occurred in the Emergency Department (ED).

This affected MR # 17 and had the potential to affect all patients treated at the facility.

Findings include:

Facility Policy: Title: Medication-Home Medications
Review Date: 08/10/2016

Purpose: To provide a process to manage medications brought to the institution by the patient or caregiver.

II. Medication brought from home by patient and not administered:

c. Controlled substances should be counted with 2 licensed persons (RN,[Registered Nurse] Pharmacist, MD [Medical Doctor]) ...and count documented.
d. If reconciliation occurs during pharmacy hours, the medications should be sent to the pharmacy for secure storage.
e. If reconciliation occurs after pharmacy hours, the medication should be placed in the inventoried envelop...and placed in the secure designated After Hours Pharmacy Return Bin ...
l. If the patient expires during the hospitalization, the medications will not be returned and will be destroyed per Alabama state law and regulations.

1. MR # 17 was treated in the ED on 5/30/17 with diagnoses including Generalized Weakness and Metastatic Breast Cancer.

Review of the MR revealed the patient expired in the ED on 5/30/17 at 12:38 PM. The RN documented on 5/30/17 at 1:47 PM, "Pt's [patients] medications left behind in room by family sent with pt to the funeral home. Percocet 7.5 mg (milligram) # 51 (number of tablets) tablets, Morphine 15 mg ER (extended release) # 81 tablets and Zofran 8 mg # 8 tablets."

There was no documentation the controlled substances, Percocet and Morphine were counted by 2 licensed persons or that the reconciled narcotics were sent to the pharmacy or placed in the Pharmacy Return Bin. There was no documentation the narcotics left at the facility were destroyed per Alabama state law.

In an interview on 8/17/17 at 7:45 AM, Employee Identifier # 1, Director of ED and Critical Care Services, confirmed the above findings.

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. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations

Based on the review of the policies and procedures, observations and interviews, it was determined the facility failed to ensure the staff followed the policy for hand hygiene, gloves, disinfection of medical equipment and preparation of injectable medications. This had the potential to affect all patients served by this facility.

Findings include:

Facility Policy/Procedure: Hand Hygiene Guidelines
Approval Date: 06/27/2017

Purpose: To establish a consistent hand-hygiene policy based on CDC (Centers for Disease Control and Prevention) guidelines. The CDC issued these guidelines in October 2002 in an effort to promote improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in healthcare settings.

Policy: Hand Hygiene is the most effective technique for preventing the spread of infection. Employees, physicians, and volunteers should follow established policies for hand-hygiene. The following are the CDC's recommendations for hand washing and hand antisepsis using a non-antimicrobial soap, an antimicrobial soap, or an alcohol based rub.

Procedure:

The CDC uses a system for categorizing each recommendation based on scientific data, theoretical rationale, applicability and economic impact. The CDC/HICPAC (Hospital Infection Control Practices Advisory Committee) system is as follows:

Category IA: strongly recommended for implementation and supported by well-designed experimental, clinical, or epidemiological studies.

Category IB: strongly recommended for implementation and supported by certain experimental, clinical epidemiological studies and a strong theoretical rationale.

Category IC: required for implementation as mandated by federal or state regulations or standards.

Category II: suggested for implementation and supported by suggestive clinical or epidemiological studies or theoretical rationale...

A. Indications for hand washing and hand antisepsis

8. Decontaminate hands if moving from a contaminated body site to a clean body site during patient care. (II)

9. Decontaminate hands after contact with inanimate objects, (including medical equipment), in the immediate vicinity of the patient. (II)

10. Decontaminate hands after removing gloves. (IB)

B. Hand Hygiene Technique

1. Alcohol-based Hand Rub: apply product to palm of hand, rub hands together, covering all surfaces of hands and fingers, until hands are dry. Follow manufacturer's recommendations regarding the volume or product to use. (IB).

E. Other Aspects of Hand Hygiene

5. Change gloves during patient care if moving from a contaminated body site to a clean body site. (II)

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Facility Policy/Procedure: Glove Technique
Review Date: 04/27/2017

Purpose: To provide a protective barrier to microbial transmission, to prevent contamination of hands and to assist in preventing contamination to patients.

Policy:...Hand cleaning should be done before donning gloves and after glove removal.

Procedure:

9. Wash hands after gloves are removed.

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Facility Policy/Procedure: Title: Vials Single Dose/Multi-Dose
Review Date: 08/2017

"Policy: Staff should follow safe injection and infection control practices as outlined below ...preventing the spread of infection.

Procedure:

...All vial's rubber septum should be disinfected by wiping with a sterile alcohol pad before entry ...Discard any vial if its sterility has been compromised of is questionable, even if the vial is unopened or unused ..."

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Facility Policy/Procedure: Equipment Cleaning, Disinfection and Storage
Review Date: 06/27/2017

Purpose:

A. To provide guidelines to ensure that reusable medical equipment is cleaned, disinfected, and stored appropriately.

Policy:

F. Perform low-level disinfection for noncritical patient-care surfaces and equipment that touch intact skin in between patient use and when visibly soiled.

Procedure:

A. Cleaning of Reusable Equipment

a. Clean medical devices as soon as practical after use(e.g. at the point of care).

1. During an observation of care on 8/15/17 at 1:39 PM in room 3325, Employee Identifier (EI) # 3, Licensed Physical Therapy Assistant, removed a gait belt from his/her uniform pocket. EI # 3 assisted MR # 25 with chair transfer and ambulation using a rolling walker and gait belt during ambulation.

After the physical therapy treatment was completed, EI # 3 rolled the gait belt up and put the gait belt in his/her uniform pocket. EI #3 performed hand hygiene, then exited the patient room to the nurses station. EI # 3 failed to disinfect the reusable equipment after use.

In an interview on 8/17/17 at 3:20 PM, EI # 11, Director of Therapy Services confirmed staff should clean reusable equipment after use.

2. An observation was conducted on 8/16/17 at 8:30 AM on the Medical Surgical floor to observe the passing of medications to two unsampled patients.

During the observations it was determined two unsampled patients were to receive a medication for his/her blood pressure. Prior to administration of the medication of the first sampled patient, EI # 14, Registered Nurse (RN), obtained the mobile blood pressure machine and rolled the machine into the patients room. EI # 14 washed hands and donned gloves. EI # 14 rolled the machine to the bedside and took the patient's vital signs. After completion of the vital signs, EI # 14 with the same gloves on documented in the computer and then scanned the patients bracelet and the medications. EI # 14 then opened the medications and gave them to the patient. EI # 14 then removed gloves and rolled the mobile blood pressure machine into the hallway, sanitized hands and EI # 14 rolled the mobile vital sign machine to the nurses station and plugged it in outside of the medication room. EI # 14 failed to clean the equipment per hospital policy.

EI # 14 obtained medications for the second unsampled patient and again obtained a mobile blood pressure monitor. EI # 14 entered the second unsampled patient's room and sanitized hands. EI # 14 donned gloves and obtained the patient's blood pressure before giving the patient the scheduled blood pressure medication. After obtaining the patient's blood pressure EI # 14 documented on the computer, scanned the patient's bracelet, scanned the medications and then opened all the medications all with the same pair of gloves on. After completion of the medication administration EI # 14 removed gloves and rolled the mobile blood pressure monitor into the hallway and sanitized hands. EI # 14 then rolled the monitor to the nurses station and plugged it in across from the medication room and failed to clean the equipment according to the hospital policy.

An interview was conducted 8/16/17 at 9:30 AM with EI # 16, RN Nurse Manager, who confirmed the above mentioned findings.

3. An observation was conducted on 8/16/17 at 10:15 AM on the SICU (Surgical Intensive Care Unit) to observe glucose monitoring. EI # 13, RN was observed in SICU # 6 performing a routine blood sugar. After completing the blood sugar EI # 13 removed gloves and washed hands with soap and water at the sink. After the completion of hand washing EI # 13 walked to the hand sanitizer dispenser and applied hand sanitizer. EI # 13 rubbed hands together briefly for about 5-6 seconds and then waved his/her hands in the air in an attempt to dry hands. EI # 13 attempted to don gloves and was unsuccessful as to the hand sanitizer remained wet on EI # 13's hands. EI # 13 then waved hands in the air, and donned gloves.

An interview was conducted on 8/16/17 at 10:25 AM with EI # 15, SICU Manager, who confirmed EI # 13 should not have waved his/her hands in the air to dry hands and confirmed the above mentioned findings.

4. During an observation of medication administration on 8/16/17 at 10:18 AM in room 3326, EI # 7, RN, entered unsampled patient # 6's room. EI # 7 sanitized his/her hands, donned gloves, and performed saline flush procedure. EI # 7 removed his/her gloves and documented on the computer keyboard without sanitizing his/her hands.

5. During an observation of medication administration on 8/16/17 at 10:23 AM in room 3323, EI # 7 entered unsampled patient # 10's room. EI # 7 sanitized his/her hands, then removed gloves from the glove box and placed them on the computer keyboard. EI # 7 donned the gloves and administered the patient's medication with the potentially contaminated gloves.

6. During an observation of care on 8/16/17 at 10:48 AM in room 3306, EI # 9, PCT (Patient Care Technician), entered unsampled patient # 8's room to check the patient's vital signs and blood sugar. EI # 9 checked the patient's blood sugar using a glucometer and used the potentially contaminated gloves to document the patient's information using the computer keyboard.

Further observation revealed EI # 9 did not clean/disinfect the reusable equipment (glucometer and blood pressure monitor) after leaving the patient's room and entering another patient's room.

7. During an observation of care on 8/16/17 at 10:53 AM in room 3305, EI # 8, RN, and EI # 9, entered unsampled patient # 7's room to administer medications and check the patient's vital signs. EI # 9 donned his/her gloves and checked the patient's vital signs including the patient's blood pressure. EI # 9 use the potentially contaminated gloves to document the patient's information using the computer keyboard.

8. Further observation revealed EI # 9 left unsampled patient # 7's room and went to unsampled patient # 11's room 3331 to check the patient's vital signs. EI # 9 did not clean/disinfect the reusable equipment (blood pressure monitor) between patient uses per policy.

9. On 8/16/17 at 11:00 AM, during 1 of 1 observations of care for preparation and administration of IM (intramuscular) medications in the Emergency Department (ED), EI # 2, RN, withdrew Toradol and Compazine from 2 single dose vials into 2 syringes, then performed IM administration of the 2 medications on ED patient, unsampled observation # 15.

EI # 2 did not disinfect the septum on the 2 vials with an alcohol pad before inserting the needles into the vials.

EI # 2 failed to follow the facility policy for disinfection of the septum on the medication vials.

In an interview on 8/16/17 at 11:29 AM, EI # 1, Director of the ED and Critical Care Services, confirmed staff should clean the septum of vials before inserting the needle.

10. During an observation of medication administration on 8/16/17 at 11:08 AM in room 3318, EI # 10, RN, entered unsampled patient # 9's room. EI # 10 sanitized his/her hands, used the computer key board, verified the patient's identity, donned gloves, administered insulin, removed gloves, and then documented the patient's information using the computer keyboard. EI # 10 did not sanitize his/her hands after glove removal per policy.

11. An observation of care was conducted on 8/16/17 at 11:09 AM with EI # 5, Nursing Assistant on unsampled patient # 1. EI # 5 brought the Mobile Vital Sign (VS) Monitor into the patients room with the glucometer on a hook attached to the basket. EI # 5 performed hand hygiene with alcohol based rub, donned gloves, and performed the blood sugar with the glucose monitor.

EI # 5 then went to the computer keyboard with the same pair of gloves used to obtain the blood glucose and began entering data into the computer. EI # 5's phone began ringing and EI # 5 entered her uniform pocket with the same pair of gloves and answered the phone. EI # 5 went back into her uniform pocket and retrieved a piece of paper and pen and began taking notes with the same pair of gloves as stated above. EI # 5 then replaced the piece of paper and pen into her pocket.

EI # 5 took a temporal thermometer out of the Mobile VS Monitor basket and took the patient temperature with the same pair of gloves as stated above. EI # 5 replace the temporal thermometer back into the Mobile VS Monitor basket without disinfecting. EI # 5 then went back to the computer and began entering data with the same pair of gloves.

EI # 5 removed the gloves, obtained a Sani-cloth and began wiping the Mobile VS Monitor, temporal thermometer and replaced the temporal thermometer back in the basket and did not disinfected the basket.

12. EI # 5 went to provide care to unsampled patient # 2 on 8/16/17 at 11:15 AM right after unsampled patient # 1.

EI # 5 brought the Mobile VS Monitor into the patients room, performed hand hygiene with alcohol based rub, and donned gloves.

EI # 5 reached into the uniform pocket and retrieved the same piece of paper and pen as in the room with the unsampled patient # 1. EI # 5 took unsampled patient # 2 temperature with the temporal thermometer that had been contaminated, took the temperature, and replaced the thermometer back in the basket. EI # 5 picked a patient care pad off the floor, placed the pads on the bedside table, and began entering data into the computer with the same pair of gloves.

EI # 5 removed the gloves, obtained a Sani-cloth and began wiping the Mobile VS Monitor, temporal thermometer and replaced the temporal thermometer back in the basket and never disinfected the basket.

EI # 5 failed to remove the gloves after picking supplies up off the floor and perform hand hygiene before going to the computer to enter data. EI # 5 also failed to disinfect the basket on the Mobile VS Monitor before replacing the temporal thermometer thus contaminated the temporal thermometer for the next patient.

13. An observation of care was conducted on 8/16/17 at 11:20 AM with EI # 6, Nursing Assistant with unsampled patient # 2. EI # 6 took the Mobile VS Monitor with a glucometer in a plastic bag in the basket into unsampled patient # 2's room. EI # 6 attempted to obtain enough blood from the patient to get blood glucose results and was unable. EI # 6 place the glucometer into the basket and left the room. Outside the room EI # 6 obtained a Sani-cloth and began disinfecting the Mobile VS Monitor and the glucometer. EI # 6 failed to disinfect the basket prior to placing the glucometer back into the dirty basket.

14. EI # 6 obtained more glucometer supplies from the nurses' station and went to unsampled patient # 4's room with the Mobile VS Monitor. EI # 6 checked the patient blood glucose, removed the left glove, and donned the left glove without hand hygiene. EI # 6 replaced the glucometer into the Mobile VS Monitor basket. EI # 6 then check unsampled patient's temperature with the temporal thermometer and placed it into the basket with the contaminated glucometer.

EI # 6 then removed the right glove, went into the pocket of her uniform, removed a black marker and began writing on the patient's board without hand hygiene. EI # 6 replaced the marked in the uniform pocket, regloved the right hand without hand hygiene and began entering data into the computer.

EI # 6 left the room and began disinfecting the Mobile VS Monitor. EI # 6 failed to disinfect the basket.

15. An observation of wound care was conducted on 8/16/17 at 1:12 PM with EI # 8, RN with MR # 33. EI # 8 sanitized his/her hands and explained the procedure to the patient. EI # 8 then donned his/her gloves and placed supplies on the bedside table. EI # 8 removed the patient's right leg stabilizer, ace bandage, and soiled 4 x 4 gauze. EI # 8 removed his/her gloves and donned clean gloves without sanitizing his/her hands.

EI # 8 removed the Iodoform strip from the right knee. EI # 8 removed his/her gloves and donned clean gloves without sanitizing his/her hands.

EI # 8 removed old dressing from right lower arm, then EI # 8 removed his/her gloves and donned clean gloves without sanitizing his/her hands.

An interview was conducted on 8/16/17 at 11:15 AM and 1:30 PM with EI # 12, RN, 3-North - Nurse Manager, who confirmed the above findings.