HospitalInspections.org

Based on interview, record review and policy review, the facility failed to ensure that a patient's nursing care plan was modified to include goals and interventions when the patient was placed in and remained in restraints for one discharged patient (#26) of one discharged patient's care plan reviewed, who was restrained. This had the potential to affect all patients that are restrained by failing to ensure that the patients' physical and psychological needs were met. There was one incident of physical restraint in the previous six months. The facility census was 30.

Findings included:

1. Record review of the facility's policy titled, "Care Plans," reviewed 09/12, showed:
- The plan is developed in coordination with the attending physician's plan of medical care.
- The care plans will be revised/updated as necessary and daily.
- The care plan includes care to be given, short and long-term goals and individualized interventions.

Even though requested, the facility failed to provide a policy related to the development of nursing care plan goals and interventions for patients placed in restraints.

2. Record review of Patient #26's medical record indicated physicians' orders for restraints and physician documentation that the patient remained in restraints from 06/12/14 through 06/25/14. The patient's nursing care plan, reviewed from admission to discharge, did not include goals or interventions as related to the patient when he was in restraints.

During an interview on 08/13/14 at 4:15 PM and again on 08/14/14 at 8:30 AM, Staff U, Nurse Manager, stated that Patient #26's nursing care plan should have included restraint use goals and interventions.

3. During an interview on 08/14/14 at 9:10 AM, Staff C, Administrator of Clinical Services, stated that although nursing care plans were part of the facility's Quality Assurance and Performance Improvement Plan, she did not review patients' care plans for quality of content as related to the patients' needs. "We realized we need to make some improvements".











29047

Based on observation, interview, record review and policy review, the facility failed to ensure that patients' nursing care plans were developed and kept current for three patients (#23, #24 and #25) of 14 patients whose medical records were reviewed for nursing care plan goals and interventions. This had the potential to affect all patients by failing to ensure that the patients' physical and psychological needs were met. The facility census was 30.

Findings included:

1. Record review of the facility's policy titled, "Care Plans," reviewed 09/12, showed:
- The plan is developed in coordination with the attending physician's plan of medical care.
- The care plans will be revised/updated as necessary and daily.
- The care plan includes care to be given, short and long-term goals and individualized interventions.

2. Observation on 08/11/14 at approximately 3:40 PM, showed Patient #23 breathing by mechanical ventilation (medical equipment that forces air into and out of a patient's lungs when they cannot breath on their own), with a gastrostomy tube (G-tube, tube surgically placed through the abdomen and into the stomach to instill liquid nutrition), and the patient was unable to move his right arm and hand or both of his legs and feet.

Record review of Patient #23's medical record showed:
- A History and Physical (H&P) dated 07/04/14, that indicated the patient was on a ventilator, with a G-tube, and was unable to move his right arm or hand, or either of his legs or feet.
- A physician's order dated 07/04/14 at 12:56 PM, for nutritional feedings through his G-tube.
- A physician's order dated 07/15/14 at 12:57 PM, for ventilator settings (determines the patient's breath rate and other settings related to the use of a ventilator).
- The patient's nursing care plan did not include respiratory goals or interventions as related to the patient's ventilator use, gastrointestinal (GI) or nutrition goals as related to G-tube feedings or musculoskeletal (related to the muscles or bones) goals related to the inability to move his arm or legs.

3. Observation on 08/12/14 at 8:30 AM, showed Patient #24 with a wound to the left, upper, temple area of the patient's head, which was covered by a dressing.

Record review of Patient #24's current medical record showed:
- A H&P dated 08/06/14, that indicated the patient had a cranial (head) wound infection that contained Methicillin-resistant Staphylococcus aureus (MRSA, difficult to treat infection) and Group A streptococcus (bacteria causing infection), after a craniotomy (part of the bone of the skull is removed to surgically access the brain). The patient was also leukopenic (low white blood cell count,which decreases the ability for the body to fight infection).
- Laboratory results dated 08/11/14 at 5:00 AM, of a low 2.9 white blood cell count (WBC, normal range is 4.5 to 10), which indicated leukopenia.
- The patient's nursing care plan, which was reviewed from admission to 08/13/14, did not include goals or interventions as related to the patient's wound, wound care, or leukopenia.

4. Record review of Patient #25's medical record showed a H&P dated 06/04/14, that indicated the patient had a spinal incision with an area that was draining, which was covered with gauze and a waterproof dressing to protect the wound from urine and stool. The patient was also breathing by mechanical ventilation. The patient's nursing care plan did not include goals or interventions as related to the patient's wound or wound care, and did not include goals or interventions related to ventilator use.

5. During an interview on 08/13/14 at 4:15 PM and again on 08/14/14 at 8:30 AM, Staff U, Nurse Manager, stated:
- Patient #23's nursing care plan should have included respiratory, GI, and musculoskeletal goals and interventions.
- Patient #24's nursing care plan should have included wound care and infection prevention goals and interventions.
- Patient #25's nursing care plan should have included wound and ventilator goals and interventions.

6. During an interview on 08/14/14 at 9:10 AM, Staff C, Administrator of Clinical Services, stated that although nursing care plans were part of the facility's Quality Assurance and Performance Improvement Plan, she did not review patients' care plans for quality of content as related to the patients' needs. "We realized we need to make some improvements".

Based on interview and record review, the facility failed to ensure that intravenous (IV, in the vein) medications were compounded (mixed) using sterile procedure when compounded after pharmacy hours by one staff (Staff V), Registered Nurse (RN), of one staff who compounded IV medications after pharmacy hours. This had the potential to lead to contamination of the IV medications and result in infection or death of the patient, and could affect any patient who received IV medications mixed after pharmacy hours. There was one instance of IV medication compounding after pharmacy hours over the previous six months. The facility census was 30.

Findings included:

1. Even though requested, the facility failed to provide a policy related to compounding IV medications by pharmacy staff, or non-pharmacy staff.

2. Record review of a form titled, "Pharmacy Supplies Sign Out Sheet," (indicated medications mixed and removed from pharmacy when the pharmacy was closed), showed an entry dated 07/04/14 for two Vancomycin (antibiotic, medication to treat infections) IVs, and one Zosyn (antibiotic) IV, which was removed by Staff V.

3. During an interview on 08/12/14 at 9:00 AM, Staff T, Director of Pharmacy, stated that Staff V mixed three IV antibiotics in the pharmacy hood (equipment used to compound sterile IV medications or fluids to prevent contamination with microorganisms) on 07/04/14, after the pharmacy had closed for the day. Staff T stated that the IVs were mixed by Staff V, under the direction of the on-call pharmacist, who provided directions by phone while Staff V compounded the antibiotics. Staff T stated that she assumed nursing leadership had provided IV compounding and proper hood use education and competency verification to all charge nurses and supervisors, since they were allowed to compound medications in the pharmacy after pharmacy hours.

During an interview on 08/14/14 at 4:15 PM, Staff V stated that when she mixed the IV antibiotics in the pharmacy, she did not use the hood, did not realize she needed to use the hood and was not trained to use the hood. Staff V added that she believed Staff T was the on-call pharmacist on the phone who guided her through the mixing process, and that Staff T was aware she was not using the hood when mixing the medications. Staff V stated that mixing IVs in the pharmacy by non-pharmacy staff did not happen often, but did happen occasionally.

During an interview and concurrent record review of Staff V's employee education on 08/13/14 at 3:30 PM, Staff F, Director of Human Resources, stated that she was not aware of any education that nurses received related to compounding medications under the hood in the Pharmacy. Staff V's education file showed no education or competency related to compounding IV medications in the pharmacy hood.

During an interview on 08/14/14 at 9:10 AM, Staff C, Administrator of Clinical Services, stated that she was not aware non-pharmacy staff were required to use the pharmacy hood to mix IV medications after hours, and confirmed that nursing staff had not been trained to use the pharmacy hood when mixing IV medications.






29511

Based on observation, interview, record review, and policy review the facility dietary staff failed to keep the can opener clean. This failure created an opportunity for debris on the can opener to cause food borne illness and was a risk to all patients and staff that consumed food from the kitchen. The facility census was 30.

Findings included:

1. Record review of facility's policy titled, "Policy Diet 100," reviewed 4/13, showed direction for staff to clean and sanitize the can opener thoroughly after each use.

2. Record review of the Food and Drug Administration (FDA), 2013 Food Code, Chapter 4-601.11 showed the following direction: Equipment, food contact surfaces, non-food contact surfaces and utensils shall be clean to sight and touch.

3. Observation on 08/12/14 at 11:45 AM, in the facility kitchen, showed a table mounted can opener in the food preparation area with dried, blackened, tar like debris on the blade that cuts into the can, and gears behind the blade.

4. During an interview on 08/12/14 at 11:50 AM Staff N, Dietary Manager, stated that the table mounted can opener in the food preparation area was soiled and should be cleaned after each use.

During a phone interview on 08/19/14 at 11:15 AM, Staff X, Infection Preventionist, stated that she had not routinely visited the kitchen as part of her infection prevention monitoring surveillance.

Based on observation, interview, and policy review the facility failed to ensure that containers of food and food additives were marked with the date originally opened. This practice created an opportunity for expired or old food/food additives to be served and cause food borne illness. This could potentially affect all patients and staff that consumed food in the facility. The facility census was 30.
Findings included
1. Record review of the facility's policy titled, "Policy Diet 100," reviewed 04/13, showed direction to staff to clearly label all food containers with the date it was opened.
2. Observation in the kitchen on 08/12/14 at 11:50 AM showed an opened container of "Thick It" (a food additive used to thicken liquids for patient's that have difficulty swallowing) that had no date that indicated when the container was opened.
Observation in the dry food storage area of the kitchen on 08/12/14 at 12:05 PM showed an opened package of french fried onion crisps with no date that indicated when the container was opened.
3. During an interview on 08/12/14 at 12:10 PM, Staff N, Dietary Manager, stated that both of these containers should have been labeled with the date they were opened. Staff N stated that the kitchen process was to discard unused products 30 days after it was opened. Staff N stated that these undated items would be disposed of.
During a phone interview on 08/19/14 at 11:15 AM, Staff X, Infection Preventionist, stated that she had not routinely visited the kitchen as part of her infection prevention monitoring surveillance.