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Based on observation, interview and document review the hospital failed to ensure patients provided consent for personal privacy when the hospital utilized Visual Monitoring (VM), including provision of consent and education for 2 of 4 patients (P42, P46). This had the potential to affect all patients who monitored by VM.

Findings include:

P42 was observed to have a visual monitoring unit in the room on 4/5/17, at 6:55 a.m. P42 was being monitored for falls. At 9:30 a.m., P42 was interviewed. P42 indicated she was not informed/educated of the visual monitoring (VM) until she came back to her room from receiving a treatment.

The nursing flowsheet dated 4/4/17, noted P42 to be alert and oriented. The flowsheet also noted visual monitoring to be in place. A Progress Note dated "writer received VM monitor and placed in the pt's [patient's] room." The Progress Note lacked evidence of the resident and/or family being informed about the VM and if education was provided to the patient and/or family regarding the VM.

Registered nurse (RN)-C and RN-G were interviewed on 4/5/17, at 9:40 a.m. Both nurses' reviewed the electronic health record (eHR) and acknowledged the medical record lacked evidence of the patient and/or family receiving education about the VM.



15508

P46, admitted 3/16/17, was observed to have VM on 4/5/17, at 8:15 a.m. During an interview at that time, the patient stated he did not want the VM and denied having given permission for it's use. According to electronic medical record of 3/16/17, the patient was identified as an elopment risk and was placed on a 72 hour hold order. A VM was placed outside patient's room on that date. The record reflect the VM continues to be in use as of 4/5/17, but did not reflect evidence of an order having been obtained nor patient's consent for it's use.
P46, admitted 3/16/17, was observed to have VM on 4/5/17, at 8:15 a.m. During an interview at that time, the patient stated he did not want the VM and denied having given permission for it's use. According to electronic medical record of 3/16/17, the patient was identified as an elopement risk and was placed on a 72 hour hold order. A VM was placed outside patient's room on that date. The record reflect the VM continues to be in use as of 4/5/17, but did not reflect evidence of an order having been obtained nor patient's consent for it's use.

In an interview with RN-R on 4/5/17 at 8:30 a.m. she stated if a patient who was identified to have a VM refused to provide consent they would be assigned a 1:1 for continuous observation. Currently, P46 had VM in place. She did verified the electronic medical record lack evidence of patient having received education or had consented for the use of VM.

The policy for The Visual Monitoring of Fall/Safety Risk Patients, dated 7/14/14, directed register nurse to
1. Enter an order for VM into the electronic medical record.
2. Provide and document the education provided to patient and/or family;
The two patient's medical records lacked evidence of the consent and education prior to the placement of the VM which would have the potential to affect the patient's privacy.

Based on observation, interview, and document review, the hospital failed to timely obtain a licensed independent practitioner (LIP) order for the use of restraints for 3 of 7 patients (P37, P48, P34) reviewed who had restraints initiated.

Findings include:

P37's restraint order was not obtained timely following the placement of non-violent physical restraints.

P37's electronic health record (EHR) revealed on 3/3/17, at 2:00 p.m. P37 had soft bilateral wrist restraints applied. A Nursing Progress Note dated 3/31/17, at 5:40 p.m. indicated registered nurse (RN)-E had requested an order for restraints at 3:00 p.m. On 3/31/17, at 7:02 p.m. an order was entered by medical doctor (MD)-B for non-violent restraints, with the reason for use listed as "pulling tubes/lines." P37's restraint flowsheet indicated on 4/1/17, at 6:00 a.m. four side rails were elevated and identified as a restraint. P37 restraint flowsheet indicated P37 was monitored every two hours from 3/31/17, at 2:00 p.m. until the restraints (both the wrist and four side rails) were discontinued on 4/1/17, at 6:00 p.m.

On 4/4/17, at 3:20 p.m. RN-G verified P37's order for non-violet restraints had been obtained five hours after P37's restraints had been applied. RN-G stated the restraint order should have been obtained within the first hour of the restraints being placed.

On 4/5/17, at 10:25 a.m. RN-F verified P37's order for non-violent restraints had been obtained five hours after P37's restraints had been applied. RN-E stated he had attempted a couple of times to obtain a restraint order for P37's restraints, however had not received a response. RN-E stated orders for restraints should be obtained at least within the hour the restraints were applied. RN-F confirmed five hours was too long of a time lapse between when P37's restraints were placed and the time the order was obtained. RN-F verified there was a chain of command that RN-E should have followed when RN-E had not received a timely response to his request for an order for restraints for P37, RN-E should have went up the chain of command to obtain the restraints order. The Chief nursing officer (CNO) confirmed the hospital policy should be more clearly written as the "calendar day" verbiage in the initiation section of the policy/procedure could be confusing to some. The CNO verified renewal orders needed to be obtained every 24 hours.


P48's initial restraint order and renewal order were not obtained timely following the placement and continuation of non-violent physical restraints.

P48's EHR revealed that on 2/10/17, at 2:00 a.m. P48 had a soft wrist restraint placed on P48's right wrist. On 2/10/17, at 7:53 a.m. (five hours and 53 minutes after restraint applied) the order was entered by MD-C for non-violet restraints, with the reason for use listed as "pulling tubes/lines." P48's restraint flow sheet indicated on 2/12/17, at midnight a soft wrist restraint was also applied to P48's left wrist. On 2/11/17, at 8:22 p.m. a renewal order for P48's restraints was entered by MD-D (12 hours and 29 minutes after the initial restraint order). P48's restraint flowsheet indicated P48 was monitored every two hours from 2/10/17, at 2:00 a.m. until the restraints (both the left and right soft wrist restraints) were discontinued on 2/12/17, at 10:00 a.m.

On 4/5/17, at 1:57 p.m. RN-G confirmed P48's initial restraint order for non-violent restraints had been obtained over five hours after P48's restraints had been applied. RN-G also confirmed P48's restraint renewal order was obtained over 12 hours beyond the initial restraint order. RN-G stated per hospital policy the initial restraint order should have been obtained within the first hour of the restraints being applied and the renewal order should have been obtained at least every 24 hours. RN-G stated the hospital policy was not very clear.

Page two of the hospital's Restraint and Seclusion policy dated 11/22/16, indicated the order for Restraint or Seclusion includes the reason for restraint or seclusion, type of restraint (non-violent vs violent self-destructive) and duration of Restraint or Seclusions. The conditions for ordering non-violent restraints: Duration of 24 hours and may be renewed every calendar day if condition warrants.



20810

P34 was observed on 4/4/17, at 9:00 a.m., in his bed in his room in four-point restraint. P34 was quiet, with his head and torso lifted up off the bed as he looked around the room. A health care assistant (HCA)-A was sitting in a chair at the door of the patient's room.

Record review revealed a Psychiatry Consult Initial History note from certified nurse practitioner (CNP)-A, dated 4/3/17 at 2:12 p.m., showing P34 was 31 years old, had a history of schizophrenia, presented to the emergency department with shortness of breath, and part of the plan of CNP-A read, "pt [patient] should be placed on a 72 hour hold as he is not demonstrating appropriate judgement at this time--a medical emergency is also needed for this pt to allow for forcing medication, restraints, blood draws and other treatments." There was no reference to extremely aggressive or threatening behavior in this note.

An order was given by MD-A on 4/3/17, at 3:09 p.m. for a restraint for violence. The order for a restraint for violence was renewed by MD-A on 4/3/17, at 7:27 p.m., with the reason for use listed as "Severely aggressive In imminent risk of harming self or others." The order for restraints for violence was renewed by MD-B on 4/3/17, at 10:28 p.m. for the same reason, and not renewed again until 4/4/17, at 7:15 a.m. by MD-A.

RN-A reviewed P34's order record with a surveyor on the unit tour that began on 4/4/17, at 9:00 a.m., and stated that there was a gap exceeding four hours in the order history and it was the primary nurse's responsibility to get the order for violence restraints renewed in a timely manner.

RN-A was interviewed again on 4/5/17, at 9:50 a.m. and she stated she could not locate documentation in the record of P34 regarding specific violent or threatening behaviors related to the restraint order for violence.

Page two of the facility's Restraint and Seclusion policy, dated 11/22/16, read, "Violent or Self-destructive Behavior Restraints: Restraints used for the restriction of patient movement in response to severely aggressive, destructive, violent or suicidal behaviors placing the patient or others in imminent danger." Page three of the same policy read, "Conditions for ordering Violent or Self-destructive Behavior Restraints: a. Duration is based on age of patient and maybe renewed according to the following time limits: 1) Adults ages 18 years and older: 4 hours..."

Based on observation, interview, and document review, the hospital failed to ensure adequate wound monitoring was consistently provided for 3 of 7 patients (P21, P43, P47) reviewed for wound care. In addition, the hospital failed to ensure the assessment for justification for continued video monitoring was completed for 3 of 4 patients (P42, P43, P46) who were reviewed for video monitoring (VM).

Findings include:

Wound care:
P21's abdominal wound and sacral decubitus ulcer lacked consistent monitoring which included measurements of both wounds and staging of the decubitus ulcer by the hospital staff to assure continued improvement.

P21's History and Physical (H&P) dated 3/22/17, identified P21 had been admitted to the hospital with a quarter-sized decubitus ulcer just superior to the posterior superior iliac spine (PSIS) on the left side that appeared to be down to the bone. In addition, P21 had a large midline incision with the inferior aspect portion of the incision open with healthy tissue.

During observation of wound care on 4/4/17, at 9:55 a.m. registered nurse (RN)-D entered P21's room and used hand sanitizer. The wound care supplies were located in a pink plastic tub positioned on P21's bed side stand. P21 was situated on his back with the head of the bed slightly elevated. RN-D donned a pair of gloves, and exposed P21's abdomen. RN-D removed the abdominal wound dressing and wound packing from P21's abdominal wound. RN-D tossed the soiled dressing and packing into a nearby garbage can and removed her gloves, disposing them in the same garbage can. RN-D donned a new pair of gloves. RN-D did not conduct hand hygiene following the removal of her gloves and the donning of a new pair of gloves. RN-D sprayed Sea Clens (a wound cleanser) onto a 4 x 4 gauze dressing and wiped around the open wound. RN-D removed the lid from a sterile water container and poured the sterile water on another 4x4 gauze dressing. RN-D gently tucked the soaked gauze dressing into the open wound using her gloved hand. RN-D opened an adhesive dressing and placed the dressing securely over the packed abdominal wound. RN-D did not measure the abdominal wound during the dressing change.

P21's surgical consultant note dated 3/22/17, identified on P21's problem list that P21 had a sacral decubitus ulcer (lacked documentation of stage of wound or measurements) and an abdominal wound dehiscence status post an exploratory laparotomy after a polytrauma. On physical exam it was noted that the midline abdominal scare measured 3 cm and had packing in place, no signs of dehiscence, infection and no significant discharge. Recommendations included a wet to dry dressing to the abdominal wound and wound care per wound nurse for the sacral decubitus.

P21's surgical services progress note indicated daily wet to dry dressing changes, wound care per wound, ostomy, and continence (WOC) nurse for abdominal and sacral wounds.

P21's Urology consult report dated 3/23/17, indicated P21 had a sacral pressure ulcer, stage 3-4 (stage 3 - a wound extending into the tissue below the skin forming a crater and a stage 4 - a wound with full thickness loss of tissue with exposed bone, tendon or muscle) which was present upon admission.

P21's provider note dated 3/23/17, indicated P21's midline incision abdominal scar had an approximately 3 centimeter (cm) area of dehiscence (a complication of a surgical wound, which involved the breaking open of the surgical incision along the suture) with packing in place.

P21's WOC progress note dated 3/23/17, indicated wound care had been consulted for abdominal wound that was being followed by surgery services, and a stage 3 pressure injury to P21's sacrum (no measurements of either the abdominal or sacral wound was documented, nor a confirmation of the stage of the sacral wound. WOC nurse recommended for staff to do wound care as directed (moist packing).

P21's nursing progress note dated 3/24/17, indicated P21's abdominal wound had slough (dead tissue) present at the base of the wound. In addition the buttock wound had a small amount of drainage and had been packed with the entire length of the packing strip (91.4 cm) and covered with a foam dressing. The medical record lacked documentation of the measurements of the abdominal and sacral wound and the stage of the sacral wound.

P21's nursing progress note dated 3/25/17, indicated abdominal wound had dry slough at the base. Buttock wound had serosanguinous (yellowish drainage with small amounts of blood) drainage and measured 4 cm deep (documentation lacked wound measurements of the abdominal wound and length and width measurements of the sacral wound along with the staging of the sacral wound.)

P21's nursing progress note dated 3/26/17, indicated the abdominal wound had slough at the base. The coccyx wound had been packed and the dressing changed (documentation lacked with regards to wound measurements and staging of the coccyx wound).

P21's plastic surgery consult note dated 3/29/17, for the evaluation of P21's sacral decubitus ulcer indicated the sacral ulcer was approximately 1 cm x 1 cm x 3 cm.

P21's WOC progress note dated 4/4/17, indicated P21's coccyx/sacral pressure wound measured 1 cm x 1 cm x 2.5 cm with 4 cm of undermining from 7-11 o'clock (these measurements were taken upon the request of the surveyor).

P21's wound flow sheet from 3/22/17, until 4/4/17, was reviewed on 4/4/17, at 10:08 a.m. with RN-B (clinical care supervisor). RN-B verified P21's wound flow sheet lacked documentation of any measurements of the abdominal wound or the sacral/coccyx wound. In addition, RN-B confirmed P21's wound flow sheet lacked documentation of the staging of P21's sacral/coccyx wound. RN-B stated a wound assessment should be completed within 24 hours of admission which should include wound measurements (width, length, and depth), location, appearance, and stage. RN-B stated wounds should be assessed with each dressing change and measurements and stage should be documented at a minimum of weekly. In addition, RN-B confirmed the WOC nurses documentation lacked wound measurements.

On 4/4/17, at 12:41 p.m. RN-I (WOC nurse) verified P21 had been evaluated by wound care on 3/23/17, for multiple wounds. RN-I stated surgical services had been consulted for the abdominal wound so WOC had not evaluated P21's abdominal wound. RN-I confirmed the WOC evaluation note lacked measurements and staging of P21's coccyx/sacral wound. RN-I confirmed it was the expectation that wounds be thoroughly assessed and documented on at least once a week. The documentation should include location, type of wound, measurements, and appearance. RN-I stated all pressure ulcer's should be staged. RN-I stated all RN's are trained and knowledgeable regarding measuring and staging wounds. RN-I confirmed documentation was lacking on P21's wound measurements for P21's abdominal wound and sacral wound and the staging of P21's sacral wound.

On 4/4/17, at 3:22 p.m. RN-I confirmed P21's sacral/coccyx wound was currently a stage 4.


P43's coccyx pressure wound lacked consistent monitoring which included measurements and staging of the decubitus ulcer by the hospital staff to assure continued improvement.

P43's H&P dated 1/1/17, indicated P43 had pressure ulcers present upon admission.

P43's WOC Progress Note dated 1/3/17, indicated P43 had a stage 3 sacral/coccyx pressure injury and digital pictures had been taken, however unable to clearly see the numbers on measuring tape which was placed the length of the ulcer. The WOC note lacked documentation of the measurements of P43's coccyx pressure ulcer. A WOC Progress Note dated 1/23/17, indicated the measurements of P43's coccyx pressure ulcer was approximately 8 cm x 6 cm x 2 cm. A WOC Progress Note dated 1/31/17, indicated the measurements of P43's coccyx pressure ulcer was approximately 9 cm x 9 cm x 2 cm. A WOC Progress Note dated 2/7/17, indicated P43's coccyx pressure ulcer measured approximately 9 cm x 9 cm x 2 cm with undermining from 7-5 o'clock and tunneling of 3 cm at 7 o'clock. A WOC Progress Note dated 4/3/17, indicated P43's coccyx pressure ulcer measured 6 cm x 5 cm x 2 cm, with 2 cm undermining from 3-5 o'clock and 9-11 o'clock. A Stage 4 ulcer.

P43's coccyx wound flow sheet from 1/1/17, through 4/5/17, was reviewed on 4/5/17, at 2:10 p.m. with RN-G (nurse manager). RN-G confirmed the stage of P43's coccyx wound was sporadically documented, however, no measurements of the wound by the nursing staff had been documented.


P47's buttocks pressure wound lacked consistent monitoring which would include measurements of the pressure wound by the hospital staff to determine progression or improvement of pressure wound.

P47's H & P dated 4/2/17, indicated P47 was admitted with "multiple stage 3 pressure injuries on left buttock surrounded by macerated scar tissue and scar tissue on the right buttocks."

Physician Orders were given on 4/2/17, for a wound consult. The WOC consult on 4/3/17, identified "Patient presents with multiple stage 3 pressure injuries on left buttocks surrounded by macerated scare tissue and scar tissue on right buttock- all present on admission." No measurements were made of the pressure wounds.

P47 was evaluated by the WOC and directions were for "staff to continue with PRN (as needed) incontinence cares using wipes and thin layer of Critic-Aid Clear." No measurements of pressure ulcer with the evaluation.

P47's Data Flow sheets from 4/2/17 to 4/5/17, were reviewed with RN-R on 4/6/17, at 7:40 a.m. It was confirmed the record lacked any type of measurements of the pressure ulcers.

On 4/5/17, at 9:48 a.m. chief nursing officer (CNO) confirmed it was her expectation that staff followed hospital policy regarding wound monitoring and documentation. The CNO stated wound monitoring should include measurements, location, stage and appearance. The CNO stated all staff have been trained on wound staging and measuring.

Skin Safety policy dated 1/24/17, indicated all wounds and pressure injuries would be assessed and staffed (if appropriate) when noted. An updated assessment of each wound and/or pressure injury would be documented at a minimum weekly or more frequently based on wound severity. Wound assessment (supporting document to the policy) directed staff measure the wound length, width, and depth in centimeters according to hospital practice.



18623

Video Monitoring:
P42 was observed to have a visual monitoring unit in the room on 4/5/17, at 6:55 a.m. P42 was being monitored for falls.

The nursing flowsheet dated 4/4/17, noted P42 to be alert and oriented. The flowsheet also noted visual monitoring to be in place. A Progress Note dated "writer received VM monitor and placed in the pt's [patient's] room."

Registered nurse (RN)-C and RN-G were interviewed on 4/5/17, at 9:40 a.m. Both nurses' reviewed the electronic health record (eHR) and acknowledged the medical record lacked evidence of the patient being re-assessed every four hours.


P43 was observed to have a visual monitoring unit in the room on 4/5/17, at 6:55 a.m. P43 was being monitored for falls.

Anursing order was initiated on 3/11/17, for the need of VM. The nursing flowsheet dated 3/11/17, noted P43 to be alert and oriented. The flowsheet also noted visual monitoring to be in place.

RN-B was interviewed on 4/5/17, at 9:40 a.m. and RN-B reviewed the electronic health record (eHR) and acknowledged the medical record lacked evidence of the patient being re-assessed for VM need every four hours.



15508

P46, admitted 3/16/17, was observed to have VM on 4/5/17 ,at 8:15 a.m. During an interview at this time, the patient stated he did not want the VM and denied having given permission for it's use. According to electronic medical record of 3/16/17, the patient was identified as an elopement risk and therefore a VM was initiated on 3/16/17. As of 4/5/17, the record reflected the VM continued to be in use, but lacked evidence of an order for it's use.

In a interviewed with RN-R on 4/5/17, at 8:30 a.m. she stated if a patient refuses to provide consent then a 1:1 was assigned for continuous observation. P46, did not have a 1:1 in place. RN-R did state the every morning the charge nurse reviews the VM for continued need. She verified the electronic medical record lacked evidence of an order or if patient gave consent for the use of VM.

In review of P46's medical record from 3/16/17 through 4/4/17, lacked evidence of consistent registered nurses assessments of VM every four hours.

The policy for The Visual Monitoring of Fall/Safety Risk Patients dated 7/14/14, directed register nurse to:
"3. Assessments of patient every 4 hours for the need to continue visual monitoring.
4.The patient and family will be informed by RN that contiuous visual monitoring will be utilized to ensure patient safety and educated on reasson for intiation and discontinuation."

Based on observation, interview and record review, the hospital was found to be out of compliance with the Condition of Participation related to the Physical Environment (42 CFR 482.41) due to lack of compliance with Life Safety Code requirements. This had the potential to affect any current and future patients.

Findings include:

Refer to Life Safety Code inspection tags: K163, K223, K311, K324, K345, K351, K363 and K914.

The cumulative effect of these systemic problems resulted in the Hospital's inability to ensure safety from fire therefore they were unable to meet this condition.

Based on observation, interview, and document review, the hospital failed to ensure appropriate hand hygiene was performed during dressing change observations for 1 of 3 patients (P21) observed during wound care; and failed to ensure Tuberculosis screening of staff was conducted/documented in accordance with appropriate protocols for 17 of 29 staff whose personnel records were reviewed.

Findings include:

P21's History and Physical (H&P) dated 3/22/17, identified P21 had been admitted to the hospital with a quarter-sized decubitus ulcer just superior to the posterior superior iliac spine (PSIS) on the left side that appeared to be down to the bone. In addition, P21 had a large midline incision with the inferior aspect portion of the incision open with healthy tissue.

On 4/4/17, at 9:55 p.m. registered nurse (RN)-D entered P21's room and used hand sanitizer. Wound care supplies were located in a pink plastic tub positioned on P21's bed side stand. P21 was laying on his back with the head of the bed slightly elevated. RN-D donned a pair of gloves, and exposed P21's abdominal wound. RN-D removed the abdominal wound dressing and wound packing from P21's abdominal wound. RN-D tossed the soiled dressing and packing into a nearby garbage can and removed her gloves, and disposed them in the same garbage can. RN-D donned a new pair of gloves. RN-D did not wash her hands nor used hand sanitizer following the removal of her gloves and prior to the donning of a new pair. RN-D sprayed Sea Clens (a wound cleanser) onto a 4 x 4 gauze dressing and wiped around the open wound. RN-D removed the lid from the sterile water container and poured the sterile water on another 4 x 4 gauze dressing. RN-D gently tucked the soaked gauze dressing into the open wound using her gloved hand. RN-D opened an adhesive dressing and placed the dressing securely over the packed abdominal wound.

On 4/4/17, at 10:01 a.m. RN-D confirmed during R21's abdominal wound dressing change RN-D had not washed her hands nor used hand sanitizer following the disposal of the soiled dressing and removal of her gloves; and prior to donning a new pair of gloves to complete the dressing change. RN-D stated she should have used hand sanitizer following the removal of the soiled gloves and prior to putting on a new pair of gloves.

On 4/4/17, at 2:32 p.m. RN-I (wound care nurse) entered R21's room and used hand sanitizer. Wound care supplies were located in a pink plastic tub positioned on P21's bed side stand. RN-I donned a pair of gloves and positioned P21 onto his right side with P21's bottom exposed. P21 was observed to have a stage 4 pressure ulcer (a wound with full thickness loss of tissue with exposed bone, tendon or muscle) on R21's coccyx/sacral area which was not covered by a dressing. RN-I stated P21's dressing had just been removed by RN-D. RN-I stated she was going to clean P21's wound as RN-I was not sure if RN-D had cleaned it. RN-I sprayed Sea Clens directly onto P21's coccyx/sacral wound. RN-I used a 4x4 gauze and wiped the wound from the edges of the wound outward in a circular motion. RN-I disposed of the gauze, removed her gloves and disposed of them in a nearby garbage can. RN-I donned a new pair of gloves. RN-I did not wash her hands nor used hand sanitizer following the removal of her gloves and prior to donning a new pair. Using a cotton tipped swab RN-I measured the depth and undermining of R21's wound. RN-I proceeded to measure the length and width of P21's wound, and took a picture of the wound with a digital camera. RN-I then moistened a package of gauze AMD (antimicrobial packing strip) with sterile water. Upon the retrieval of more cotton tipped swabs, RN-I used the tip of the swab and gently packed the wound with the moistened AMD packing strip. Using a scissors from the dressing changing kit, RN-I cut the excess tail of the packing strip and placed an adhesive dressing over the packed coccyx/sacral wound. RN-I removed and disposed of her gloves and upon exiting P21's room; RN-I used hand sanitizer.

On 4/4/17, at 2:59 p.m. RN-I confirmed during P21's coccyx/sacral dressing change RN-I had not used, nor was it her routine practice to use hand sanitizer or wash her hands upon removal of gloves and prior to the donning of a new pair. RN-I states she just uses hand sanitizer upon entering and exiting a patient's room.

On 4/5/17, at 9:48 a.m. chief nursing officer (CNO) confirmed it was her expectation that staff followed hospital policy and procedure with regards to hand hygiene practices during dressing changes. The Infection Preventionist also confirmed staff should wash their hands or use hand sanitizer before and after the removal of gloves.

The hospital's Hand Hygiene policy dated 9/22/15, indicated hand hygiene should be performed after removal of gloves.
The hospital's Dry and Moist-to-Dry Dressing procedure [undated] indicated hand hygiene should be performed following the removal of gloves and prior to the donning of a new pair of gloves.




18623

Seventeen of 29 employees (E1 through E17) who had Tuberculin Skin Test (TST) administered, did not have the induration identified along with whether or not the TST was positive of negative:

Employee 1 had a TST completed and the result was read on 2/9/17. The result was interpretated as "negative" but the employee record lacked evidence of interpreation of the induration.

Employee 2 had a TST completed and the result was read on 5/18/16. The result was interpretated as "negative" but the employee record lacked evidence of interpreation of the induration.

Employee 3 had a TST completed and the result was read on 8/12/16. The result was interpretated as "negative" but the employee record lacked evidence of interpreation of the induration.

Employee 4 had a TST completed and the result was read on 8/17/16. The result was interpretated as "negative" but the employee record lacked evidence of interpreation of the induration.

Employee 5 had a TST completed and the result was read on 2/12/17. The result was interpretated as "negative" but the employee record lacked evidence of interpreation of the induration.

Employee 6 had a TST completed and the result was read on 2/9/17. The result was interpretated as "negative" but the employee record lacked evidence of interpreation of the induration.

Employee 7 had a TST completed and the result was read on 2/12/17. The result was interpretated as "negative" but the employee record lacked evidence of interpreation of the induration.

Employee 8 had a TST completed and the result was read on 3/15/17. The result was interpretated as "negative" but the employee record lacked evidence of interpreation of the induration.

Employee 9 had a TST completed and the result was read on 1/10/17. The result was interpretated as "negative" but the employee record lacked evidence of interpreation of the induration.

Employee 10 had a TST completed and the result was read on 9/16/16. The result was interpretated as "negative" but the employee record lacked evidence of interpreation of the induration.

Employee 11 had a TST completed and the result was read on 1/12/16. The result was interpretated as "negative" but the employee record lacked evidence of interpreation of the induration.

Employee 12 had a TST completed and the result was read on 1/7/17. The result was interpretated as "negative" but the employee record lacked evidence of interpreation of the induration.

Employee 13 had a TST completed and the result was read on 12/9/16. The result was interpretated as "negative" but the employee record lacked evidence of interpreation of the induration.

Employee 14 had a TST completed and the result was read on 9/23/16. The result was interpretated as "negative" but the employee record lacked evidence of interpreation of the induration.

Employee 15 had a TST completed and the result was read on 3/3/17. The result was interpretated as "negative" but the employee record lacked evidence of interpreation of the induration.

Employee 16 had a TST completed and the result was read on 1/19/17. The result was interpretated as "negative" but the employee record lacked evidence of interpreation of the induration.

Employee 17 had a TST completed and the result was read on 2/12/17. The result was interpretated as "negative" but the employee record lacked evidence of interpreation of the induration.

During interview with the Medical Director responsible for the hospital's infection control program on 4/5/17 at 3:00 p.m., she confirmed the expectation was tuberculin skin tests would be read to include induration along with interpretation as to whether positive or negative.

On 4/6/17, at 11:00 a.m. the manager for Employee health and Wellness was interviewed and acknowledged the TST reading for E1 through E17 should have both the induration and interpretation completed for the TST.

Based on interview and document review, the facility failed to ensure their policies were implemented for notification to the Organ Procurement Organization (OPO) for 2 of 5 patients (OPR1, OPR2) reviewed for whose death was imminent.

Finding include:

Five records were reviewed who met the facility policy definition of imminent brain death or cardiac death. According to the 11/26/13, facility policy titled Organ/Tissue/Eye Donation After Death, the OPO shall be notified within one hour of meeting the criteria for imminent brain death, circulatory death, or cardiac death.

Organ Procurement Record (OPR1)'s medical record was reviewed and indicated the patient met the criteria of brain death on 1/31/17, at 7:00 a.m. The OPO was notified on 1/31/17, at 3:00 p.m.

OPR2's medical record was reviewed and indicated the patient met the criteria of brain death on 2/5/17, at 9:16 a.m. The OPO was notified on 2/11/17, at 5:59 p.m.

On 4/5/17, at 9:12 a.m., RN-N, who worked in an of the intensive care unit, stated the OPO should be called with in 4 hours. RN-N then clarified and stated within 2-4 hours.

On 4/5/17, at approximately 9:20 a.m., RN-O, who worked in an intensive care unit, stated the OPO should be called within 4 hours.

On 4/5/17, at 9:30 a.m., RN-J, with responsibility for implementation of the hospitals' organ procurement program, stated staff are provided annual training on organ donation and are told to call within one hour. RN-J stated she would expect staff to call the OPO within one hour and to be able to verbalize that the OPO should be called within 1-2 hours. RN-J also stated the OPO had not been notified within one hour of meeting the criteria for OPO notification in the case of OPR1 and OPR2.

On 4/5/17, at approximately 3:00 p.m., the hospital's Life Source (OPO) Coordinator (OPO-C) was interviewed by telephone. OPO-C confirmed OPR1 and OPR2 were not reported timely and that timely notification must be within one to two hours of meeting the triggers for imminent death.