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Based on observation, interview and record review, the facility failed to maintain a clean sanitary environment and timely meet the individual basic care needs for 2 patients (P-5 and 15) of 19 patients reviewed for basic care, resulting in an unclean and unmonitored environment, potential for unrecognized safety events, increased patient dissatisfaction, and denial of patient rights to patient centered and dignified care in a safe setting. Findings include:

On 10/15/24 at 1155, during the tour of Medical Surgical unit (2 West) with Clinical Improvement Coordinator, Staff Y, and Nurse Manager, Staff M, the clean storage room was observed on the unit. The floor in the room looked worn, covered with dark gray and black stains, and residue. Multiple paper and plastic debris, supplies packages, vacutainers, and tape rolls were found under the storage shelves. When asked how often this room was cleaned Staff M stated that is supposed to be done daily. When asked why the floor was so dirty and unsanitary appearing, Staff Y stated that it was clean, but old and needed a replacement.

"Infection Control in the Environment of Care Attachment Cleaning Grid" (Policy # 2 IC 033) was reviewed on 10/16/24 and revealed:
"Clean utility room- locker shelves. Responsible group or person- EVS high dusting and exterior. Frequency- visibly dusty or soiled."

Cleaning grid attachment provided by facility did not have clean utility/storage room floors cleaning frequency and responsible group mentioned in it.


50585

On 10/15/2024 at 1040, during a tour of the medication room in the Medical Intensive Care Unit, the thermometer attached to the medication refrigerator was observed to contain a label with a calibration due date of January 2024. An emergency eyewash bottle with an expiration date of 10/2021 was observed in the corner of the countertop and available for use. Clinical Improvement Coordinator Staff E was queried and confirmed the findings at the time of discovery.


47415


On 10/15/2024 at 1040, during a tour of the medication room on 4 West Medical Surgical Unit, review of the medication refrigerator temperature logs for October 2024, revealed that no daily temperature was recorded on October 3, 4, 5, 6, 10, 11, and 12, 2024. RN staff X was queried and confirmed findings at the time of discovery.

Unit Manager Staff T was asked whose responsibility it was to record refrigerator temperatures in the medication room, and she responded she was responsible and accountable to make sure the temperatures are logged.

On 10/15/24 at 0914, a conversation with the caregiver (complainant), by phone, revealed P-5 called her many times stating his call light was on to request help with toileting, but no staff were coming to help. She (the complainant) had to call the nursing desk to tell someone to go to the room to help him. During his stay, he fell getting up unassisted to toilet.

On 10/16/24 at 1400, medical record review revealed P-5 had an unwitnessed fall on 6/5/24. (found on floor by RN), An assessment post fall included a computerized tomography of head (negative for intracranial hemorrhage) and a left pelvis X-ray, that noted an acute left intertrochanteric fracture. P-5 went to surgery for a left intramedullary nail (IMN) procedure on 6/6/24.

On 10/16/24 at 1430, the fall event and incident logs were reviewed, no entry was found on these logs for P-5. Interview with Staff B at the time of this event log review, confirmed there were no event reports or follow up documentation available regarding P-5's fall.

Review of facility policy titled. "Event Reporting", dated 1/3/20 revealed, "A reportable event means an event that is not consistent with the routine operation of the Hospital or the routine care of a patient or patients ... "Patient Safety Reporting System" or "PSRS" is the mechanism for the Hospital Staff Member to complete an Event Report for patient safety events ... Hospital Staff Members must complete and submit an Event Report as soon as possible ... "Event Manager" means the role typically assigned to a subject matter expert who is the Hospital's identified authority on the event type(s) assigned. This individual sees all events of their assigned event type(s) - regardless of where the events occur ... Examples ...falls champion as falls event manager."

On 10/16/24 at 1400, review of record for P-5 revealed, on 6/5/2024 at 0649, Clinical Nurse Practitioner (CNP) was paged to assess P-5 after a fall event. Patient was assessed at bedside. P-5 stated he fell when he attempted to get up to urinate. P-5 assessed as alert and orientated x 4. Review of nursing note of 6/11/24 at 0323, revealed that patient was found with stool on him, the bed and the floor.

On 10/15/24 at 1030 during facility tour, an interview was conducted with P-15 in room 4091, who stated he is blind, and it takes a long time for staff to answer the call light every time he puts it on, and sometimes the response time is more than an hour. There have been delays in setting him up for meals and the food gets cold, delays with repositioning, and delays with toileting requests. When he asks about the delays in answering the light, he said the staff replies they are busy.

On 10/16/24 at 1500, review of policy titled, "Patient Rights and Responsibilities" dated 2/10/22 revealed that, "Patients will receive the same treatment and consideration as anyone else regardless of age... status...physical or mental disability ... Patients can expect their dignity as a human being to be recognized and respected."

Based on interview and record review, the facility failed to ensure that registered nurses supervised and evaluated the nursing care for 3 patients (P-2, 4 and 5) of 19 patients reviewed and failed to develop comprehensive care plans for 2 patients (P-4, 5) of 19 patients reviewed, resulting in serious adverse outcomes to patients, including harm and physical decline. Findings include:

See Specific Tags:

A-395 Failure to ensure that nursing staff supervise and evaluates patients' care.

A-396 Failure to ensure that nursing staff develops patient centered individualized plan of care.

Based on interview and record review, the facility failed to ensure that registered nurses supervised and evaluated the nursing care for 3 patients (P-2, 4 and 5) of 19 patients reviewed, resulting in facility acquired unstageable pressure injuries, patients' deterioration in health status and preventable decline. Findings include:

On 10/16/24 at 1400, record review revealed P-5 presented to the emergency department (ED) on 4/27/24 at 1904, with chief complaint of increasing fatigue, loss of appetite, and weight loss (15 pounds in past 2 weeks). Admitting diagnosis was failure to thrive and acute kidney injury.

Review of progress notes of 5/30/24 revealed a plan to monitor strict intake and outputs, and daily weights for P-5.

Based on record review, weights for P-5 were only recorded three times during stay, from 4/24/24 - 6/12/24. Weights were recorded on 4/27/24- 45 kg, 5/27/24 - 45 kg, and 6/11/24 - 45 kg. The three (3) weights were recorded as "estimated".

Nutritional consult dated 5/7/24 revealed, P-5 had a low fiber, double portion diet ordered with high protein supplement three times daily. Nutritional Assessment on 5/27/24 revealed, P-5 had no documentation of oral meal intake in the record.

Review of record for oral meal consumption for P-5, revealed no documentation for any meal (breakfast, lunch, dinner) intake on the following dates: 4/28/24, 4/29/24, 4/30/24. No meal entries recorded on any day in May 2024, and no meal entries documented in the record on 6/1/24, 6/2/24, 6/7/24, 6/8/24, 6/9/24, 6/10/24, 6/11/24, or 6/12/24. Supplement intake not documented in the record.

On 10/16/24 at 1300, interview with CNO Staff A revealed that it is her expectation that nursing staff follow policy and procedures, and standards of practice for nursing.

On 10/16/24 at 1530, review of facility policy titled, "Assessment Monitoring Guidelines Acute Care", dated 2/16/19, revealed, "OBJECTIVE/PURPOSE: To provide guidelines for routine monitoring and assessment of general acute care (medical-surgical) adult patient population ... Intake includes all fluids delivered orally, parenterally, and via irrigation or feeding tubes ... This policy sets minimal guidelines for the Acute Care (medical-surgical) adult patient. These standards do not preclude clinical judgment".


50585

According to the medical record, P-2 was admitted on 4/15/2024 and was discharged on 6/1/2024. P-2's had an order on 4/18/2024 for a daily CHG bath. There was no documentation of P-2 receiving a CHG bath on 4/23/2024, 5/03/2024, and 5/7/2024. Clinical Improvement Coordinator Staff E confirmed the findings at the time of discovery.

On 10/15/2024 at 1020, Physician Staff K was interviewed and was queried if a chlorhexidine gluconate (CHG) bath required an order and they said "yes", and the order was usually "daily."
On 10/15/2024 at 1025, Medical Intensive Care Unit Nurse Staff D was interviewed and was asked what CHG baths were used for and they said to "disinfect patient" and the frequency was normally "daily" sometimes "every shift."

P-2's chart review revealed that "peri-care" was not documented as performed on 4/23/2024, 4/24/2024, 4/28/2024, 5/3/2024, 5/7/2024 and 5/12/2024 and "oral hygiene" was not documented as performed on 4/23/2024 through 4/28/2024, 5/2/2024 through 5/4/2024, 5/7/2024, 5/8/2024, 5/10/2024 through 5/16/2024, 5/19/2024, 5/21/2024, 5/22/2024, 5/25/2024 through 5/27/2024, and 5/29/2024.

On 10/16/2024 at 1100, Wound Care Nurse Staff HH was interviewed and was asked if a patient's pressure injury was documented in the Facility Acquired Pressure Injury log, does that mean the pressure injury was acquired at the facility, and they said "yes." Staff HH was asked about frequency of repositioning the patient, and they revealed that the patient turn documentation was "every two hours" and "every Monday" the pressure injury was measured.

According to the facility's Facility Acquired Pressure Injury log for May 2024, P-2 had a reported facility acquired pressure injury on the right ankle, Stage II.

According to the medical record, the Medical Care Intensive Care Unit note on 4/15/2024 at 2047 (date of admission) revealed that P-2 had Stage II pressure injuries on both left and right buttock as well as Stage I lower lumbar decubitus ulcer.

On 4/17/2024 at 1700, a pressure injury on the sacrum midline was recorded for P-2 and the injury measured 5 centimeters (cm) x 8 centimeters (cm). On 4/19/2024 at 1600, the pressure injury was recorded as stage III. On 5/16/2024 at 1400, the pressure injury was recorded as stage IV.
On 4/20/2024 at 1600, a pressure injury on the lateral back was recorded. On 4/26/2024 at 1600, the pressure injury was recorded as stage I. On 5/9/2024 at 0300, the pressure injury was recorded as stage III.

On 4/22/2024 at 1200, a pressure injury (facility acquired) on the right lateral ankle was recorded without a stage status. On 5/6/2024 at 0445, the pressure injury was recorded as stage II and the pressure injury measured 3 cm x 3 cm.

According to P-2's medical record, documentation revealed that P-2 was not repositioned every 2 hours on the following dates and times: 4/18/2024 at 2000, 2200, 4/19/2024 at 0000, 0200, 0400, 1800, 4/20/2024 at 2200, 4/21/2024 at 0000, 0200, 0400, 4/22/2024 at 0200, 0400, 1400, 1600, 1800, 2000, 2200, 4/23/2024 at 0000, 0200, 0400, 1600, 4/24/2024 at 0400, 4/25/2024 at 0200, 0400, 1000, 1200, 1400, 1600, 1800, 2000, 2200, and 4/26/204 at 0000, 0200, 0400.



45246

P-4 record review on 10/16/24 revealed that he was admitted to facility on 3/5/2024 for urgent evaluation following a motor vehicle collision as a pedestrian. On 3/8/24, he underwent cervical spine surgery (C7-T1 Anterior Cervical Discectomy and Fusion) with significant blood loss that was managed with transfusions and fluid replacements. Postoperatively, he was started on tube feeds. By 3/10/24, he remained intubated and sedated. Plans were made for a tracheostomy and Percutaneous Endoscopic Gastrostomy (PEG) tube placement. Carotid angiogram and stenting were performed on 3/12/24 and a retrograde left femur intramedullary nail surgery was performed on 3/14/24 to repair his broken hip. On 3/19/24 MRI revealed diffuse axonal injury (traumatic brain injury that can lead to a coma and/or physical and cognitive impairment), contributing to a poor neurological prognosis. By 4/8/24, after detailed discussions with family, a consensus was reached to transition patient to a hospice care. By 4/9/24, a referral to hospice care was initiated. On 4/10/24 P-4 was taken off the ventilator and transferred to a medical surgical unit in the same facility.

Case Management reassessment note dated 4/14/24 1526 revealed: "Patient is signed with [name] Hospice".
Next Case Management reassessment note dated 4/20/24 0932 indicated that P-4 was "disenrolled from inpatient hospice care" by his sister.

Palliative care provider note dated 5/31/24 1231 revealed that provider spoke to a Hospice Director, Staff EE, who stated that patient was enrolled with Hospice up until 4/18/24. Per patient's sister P-4 wanted to live and she wanted him to be removed from the hospice.

Internal Medicine Discharge Summary note dated 6/11/2024 2142 revealed the following: "patient's sister would like to speak with hospice team directly as she is requesting inpatient hospice. Disposition: Patient is not GIP (general inpatient) hospice appropriate. Guardian (sister) no longer wants hospice care. LTAC (long term acute care facility) was requested, and patient was transferred to [facility name]." Patient was discharged from facility on 6/12/24.

Based on above findings, P-4 was admitted to facility from 3/5/24 to 6/12/24 with a hospice care enrollment from 4/10/24 to 4/18/24.

Review of nursing admission skin assessment documented on 3/5/24 2300 (after his admission to facility on 3/5/24) did not reveal any pressure injuries present on admission.

There was a nursing assessment documentation dated 3/16/24 2000: "Coccyx Medial pressure ulcer- Unstageable, deep tissue injury, evolving, measurements 0.5 x 0.5 cm, intact and discolored, wound status- deteriorating."

Nursing assessment documentation dated 3/25/24 0800: "Coccyx Medial pressure ulcer- Stage II, measurements 1.5 x 1 cm, wound status- deteriorating."

Nursing assessment documentation dated 04/06/24 0800: "Coccyx Medial pressure ulcer- Stage I, improving."

Record review did not reveal nursing Plan of Care for risk for impaired tissue integrity after identifying deep tissue injury on 3/16/24. No Plan of Care was initiated by nursing for impaired skin integrity after P-4 pressure injury deteriorated to Stage II and until patient was transferred to a different unit on 4/10/24.

Further nursing skin assessment documentation review revealed the following data:
On 4/27/2024 19:00 "Coccyx pressure ulcer, Unstageable - deep tissue injury evolving.
No nursing plan of care for skin impairment was initiated after this assessment."

On 4/30/24 1800 "Coccyx pressure ulcer, Unstageable - deep tissue injury evolving, present on arrival to unit, silicone border foam dressing."

On 5/06/24 0200 "Coccyx pressure ulcer, Stage II ..."

On 5/10/2024 1100 "Coccyx pressure ulcer, Unstageable- slough and/or eschar, wound bed- necrotic tissue, slough; wound exudate- sanguineous..."

On 5/13/2024 0600 "Coccyx pressure ulcer, Stage III, wound status- deteriorating..."
No wound care consult was initiated after this nursing skin assessment.

On 5/27/2024 1700 "Coccyx pressure ulcer, Stage IV, wound bed- necrotic tissue, eschar, wound exudate- sanguineous, moderate..."

On 5/29/2024 1000 "Coccyx pressure ulcer, measurements 18 x 24 cm, wound status- unchanged.
Further record review revealed the following nursing skin assessments and documentations."

On 4/30/24 1800 "Back right lateral pressure ulcer, Stage II ..."
No nursing assessments were documented for this pressure injury to the right lateral back from 5/02/24 to 5/29/24.

On 5/29/2024 1000 "Back right lateral pressure ulcer, unstageable - deep tissue injury evolving, measurements 9.5 x 3 cm..."

On 5/27/24 1700:
1) "Right scapula pressure ulcer, Stage III, wound exudate- sanguineous, moderate..."
2) "Left lateral knee pressure ulcer, Stage II, wound exudate- sanguineous, moderate, wound status- unchanged."

On 5/29/2024 1000:
1) "Right scapula pressure ulcer, measurements 5 x 9 cm."
2) "Left lateral knee pressure ulcer, Stage III, measurements 9.5 x 3 cm."
No wound consult was placed after identifying above two pressure ulcers on 5/27/24. No nursing plan of care for skin impairment was initiated after this assessment.

On 5/29/24 1743:
1) "Left posterior thigh pressure ulcer, Stage III, measurements 5 x 5 cm, wound status- deteriorating..."
2) "Right gluteal pressure ulcer, Stage III, measurements 7.5 x 7.5 cm."
No wound consult was placed after identifying above two pressure ulcers on 5/29/24. No nursing plan of care for skin impairment was initiated after this assessment.

Further record review for this encounter from 4/10/24 to 5/30/24 did not reveal any provider notes regarding the wounds. There was a provider order dated 4/12/24 1519 and discontinued on 5/31/24 0102 for Nutrition and food services consult.

Wound management consult note signed by Staff HH, wound care nurse, and dated 6/3/24 0930 indicated the following. Wound assessment:

"1) Sacral unstageable pressure injury, 19.5 x 14 x 0.2 cm (length/width/depth), wound bed- dry black necrotic tissue.
2) Right trochanter unstageable pressure injury, 5 x 5 x 0.2 cm, wound bed- dry black necrotic tissue.
3) Right proximal scapula unstageable pressure injury, 7 x 11 x 0.2 cm, wound bed- moist necrotic tissue.
4) Right distal scapula unstageable pressure injury, 6 x 11 x 0.2 cm, wound bed- dry black necrotic tissue.
5) Left lateral thigh unstageable pressure injury, 1.5 x 2.5 cm, wound bed- dry black necrotic tissue.
6) Left lateral knee unstageable pressure injury, 6.5 x 1 x 0.2 cm, wound bed- dry black necrotic tissue.
7) Left medial knee unstageable pressure injury, 5 x 3 cm, wound bed- dry black necrotic tissue.
8) Left anterior knee unstageable pressure injury, 5 x 1 cm, wound bed- dark flattened intact.

Spoke with staff to have patient scheduled for q2 (every 2 hours) turning ... Bedside nurses to complete dressing changes as ordered. If deterioration or development of wounds occurs, please reconsult.
Sacro-coccyx, Right Trochanter, Right Distal & Proximal Scapula, Left Lateral Thigh, Left knee pressure injury:
1. Clean and soak wounds for 5-10 minutes with Vashe (topical super-oxidized solution specifically formulated to combat bacteria and facilitate wound healing) soaked gauze and pat dry with gauze.
2. Apply dime thick layer of Triad (Zinc-oxide based hydrophilic paste) to wound.
3. Cover with Allevyn (multi-layered dressing with adhesive boarders).
4. Provide surface cleansing after incontinence episode and reapply Triad if needed.
5. Completely remove Triad with mild soap and lukewarm water and replace Q72H.

To be completed daily:
1. Complete daily/PRN (as needed) bathing using lukewarm water and pH-balanced skin cleanser or CHG solution.
2. Avoid use of incontinence brief and use single white Ultrasorb pad for proper moisture-wicking, especially on specialty beds (allows for proper microclimate).
3. Apply barrier cream to bilateral buttock/perineum if excessive moisture is noted.
4. Assess skin, wound, and all bony prominences every shift and document.
5. Protect bony prominences with use of foam wedge, pillows, or Allevyn.
6. Turn and reposition every 2 hours with assistance of foam wedge, pillows, or Turn Assist feature on specialty bed and document each shift in Plan of Care and Q2H (every 2 hours) in Activity & Intervention.
7. Offload heels with use of heel lift boots or pillows placed under patient's calves.
8. Start Pressure Injury Management Order set and complete Patient Education/Plan of Care forms each shift.
9. Consult Nutrition for Pressure Injury."

Review of the nursing documented skin assessments for P-4 revealed missing nursing wound assessments on 5/31/24, 6/01/24, 6/02/24, 6/04/24, 6/05/24, 6/07/24, 6/08/24, 6/09/24, and 6/11/24 6/10/24 (as per wound care nurse, Staff HH, recommendations above). Documentation regarding repositioning patient every 2 hours and consistent offloading heels was not evident in a provided medical record.

On 10/15/24 at 1020 during the tour of Medical intensive Care unit (MICU) nurse manager, Staff C, was interviewed regarding nurses' clinical responsibilities and documentation. Staff C stated that all nurses are responsible for their shift assessments, including skin and wounds, and appropriate documentation. When asked about initial admission assessment, Staff C said that it is expected to be completed and documented withing 24 hours period. Furthermore, if any skin conditions were identified during nursing assessments, they need to be documented with plan of care initiated as well.

On 10/16/24 at 1058 facility wound care nurse, Staff HH, was interviewed. She was asked what the process was for initiating wound consult for patients. Staff HH stated that wound consult was warranted with complex, Stage 3 and 4 wound management. For pressure injuries Stage 1 and 2 management there were binders available on each unit. They contain the wound care assessment, information and references for nurses. Staff HH also added that nursing staff can reach out to her at any time with questions related to skin or wound assessment and/or management. When asked if the expectations were for staff nurses to assess patients' skin daily and document any new findings, Staff HH stated yes.

Facility Skin and Wound Care Policy was reviewed on 10/16/24. Policy effective 7/21/21 revealed:
"I. OBJECTIVE
To provide guidelines for skin and wound care
III. POLICY
A. The RN (registered nurse) is responsible for the assessment, planning, evaluation and documentation of skin and wound care. Wounds are assessed with each dressing change and characteristics documented in the medical record.
B. Wound care is provided using [facility name] Wound and Skin Care Flow Charts as guidelines for the RN to independently make decisions and initiate orders for wound care.
I. RN staff members initiate EMR (electronic medical record) orders for pressure injury prevention and management based on patient risk assessment and/or presence of pressure injury (injuries).
K. Any pressure injury that develops 24 hours after admission to the hospital or is not documented as present on admission within 24 hours is defined as a hospital-acquired pressure injury (HAPI).
M. Patients are repositioned minimally every 2 hours. Able patients are taught to shift their body weight while in bed and chair sitting. EMR documentation of repositioning occurs in the Plan of Care under Comments. Additionally, repositioning may be documented in the activity section of the EMR."

Based on interview and record review, the facility failed to establish an individualized plan of care for two patients (P-4 and 5) of 4 patients reviewed resulting in negative outcomes for the patient.

Review of the medical record revealed that P-5 had an admitting diagnosis of failure to thrive with chief complaint of recent weight loss, greater than 15 pounds in 2 weeks. No nursing care plan was open for imbalanced nutrition to address P-5's recent weight loss, decreased appetite, or low BMI.

A nutritional note entered on 5/23/24, revealed oral meal intake was not documented in the record. Nutritional Problem recorded by dietitian was underweight, evidenced by a BMI of 15.2 Nutritionist recommendations and plan of care included: "continue double portion, high protein diet, which provided 350 calories and 20 grams of protein each, and encourage oral meal/supplement intake, and monitor weight, RN to document and trend weights."

Review of record for oral meal intake/meal consumption for P-5 revealed no documentation for meal intake on the following dates: 4/28/24, 4/29/24, 4/30/24. No entries recorded on any day in May 2024, 6/1/24, 6/2/24, 6/7/24, 6/8/24, 6/9/24, 6/10/24, 6/11/24, or 6/12/24. Supplement intake not documented. Three entries of "estimated" weight documented in the record, 4/27/24 at 45.0 kilograms (kg), 5/27/24 - 45.0 kg, and 6/11/24 - 45.0 kg

On 10/16/24 an interview with CNO Staff A revealed that it is her expectations that nursing staff follow policy and procedures, and standards of practice for nursing.


45246

On 10/15/24 at 1020 during the tour of Medical intensive Care unit (MICU), nurse manager, Staff C, was interviewed regarding nurses' clinical responsibilities and documentation. Staff C stated that all nurses are responsible for their shift assessments, including skin and wounds, and appropriate documentation. Staff C added that if any skin conditions were identified during nursing assessment, on admission or later during hospitalization, they need to be documented with the plan of care initiated as well.

On 10/16/24 P-4's record was reviewed and revealed the following documentation. P-4 was a 73-year-old male admitted to facility on 03/05/24 at 1906 post MVA (moto-vehicle incident) with multiple traumas. P-4 underwent several surgical procedures, was admitted to a Surgical Intensive Care Unit (SICU) and on 4/10/24 was transferred to a medical surgical unit after family agreed to hospice care.

Initial nursing admission skin assessment documented on 3/5/24 2300 (after his admission to facility on 3/5/24) did not reveal any pressure injuries present on admission.

There was a nursing assessment documentation dated 3/16/24 2000: "Coccyx Medial pressure ulcer- Unstageable, deep tissue injury, evolving, measurements 0.5 x 0.5 cm, intact and discolored, wound status- deteriorating."

Nursing assessment documentation dated 3/25/24 0800: "Coccyx Medial pressure ulcer- Stage II, measurements 1.5 x 1 cm, wound status- deteriorating."

Nursing assessment documentation dated 04/06/24 0800: "Coccyx Medial pressure ulcer- Stage I, improving."

Record review did not reveal a nursing Plan of Care for risk for impaired tissue integrity after identifying deep tissue injury on 3/16/24. No Plan of Care was initiated for P-4 for impaired skin integrity after the wound was assessed on 3/25/24 and evolved to Stage II. No Plan of Care for skin impairment was developed for P-4 until patient's transfer to a different unit on 4/10/24.

Nursing Plan of Care Policy was requested and reviewed on 10/16/24. Policy, Effective 3/16/22, indicated:
"I. Objective.
To document the plan of care required to meet the admitted patient's needs.
II. Scope.
Registered Nurse (RN)
IV. Policy.
The RN develops, documents and updates the patient's Plan of Care, which includes problems and goals as identified
through the episode of care.
V. Provisions.
A. The Plan of Care is initiated with the patient and is documented within the first twelve hours of patient admission.
B. The RN integrates data obtained through objective and subjective means (e.g. Admission History and Assessments) to identify patient needs and care priorities.
C. The RN collaborates with the patient, family and/or significant other to formulate the Plan of Care.
D. The RN individualizes the pre-formatted plans of care to be reflective of the patient's condition
E. The RN is responsible for reviewing, evaluating, and documenting the progress toward established plan of care goals and updates the plan of care accordingly, minimally every twelve hours. Documentation is reflective of findings from:
F. On-going and focused assessments plus additional updates to be completed to address new findings or
G. Change in the patient's condition (e.g., post-op, change in hemodynamic state, change in level of consciousness (LOC), invasive procedures)."

Based on observation, interview, and record review, the facility failed to ensure that clinical staff followed established processes and methods for preventing and controlling the transmission of infections for 1 patient (P-8) of 1 patient observed, resulting in the potential for transmission of infection and less-than-optimal outcomes for the patient. Findings include:

On 10/15/2024 at 1100, in the presence of Clinical Improvement Coordinator Staff E, Nurse Staff G was observed outside a room (P-8) that was listed as isolation precautions. Staff G gathered medications and supplies and placed the items on the surface of the computer-on-wheels device. Staff G put one glove on and proceeded to the patient care unit desk to obtain a glucometer, then put the other glove on and proceeded to open the isolation room door and enter P-8's room.

Without performing additional hand wash, Staff G was observed performing the following tasks using the same pair of gloves that were put on prior to entering P-8's isolation room and without additional hand wash. Staff G scanned all the medications at one time before administering any medication. Staff G opened P-8's isolation room door twice, once to ask for assistance for the Mobility Technician to reposition P-8 and again to announce that they were going to close the curtain to reposition P-8. Staff G spiked a medication vial. Staff G pressed buttons on the intravenous pump, moved the curtain to reposition P-8, and reopened the curtain. Staff G administered an intravenous (IV) piggyback, then placed the used IV piggyback in the trash can that was near capacity with trash. Staff G used a pencil to document information on paper and pressed keys on the keyboard to enter information into the computer. Clinical Improvement Coordinator Staff E confirmed the observations and findings.

According to the facility's policy "Facility Isolation Policy," dated 11/1/2023, the policy revealed that "Hand hygiene will be performed according to the facility's Epidemiology Hand Hygiene Policy" and that "Hand hygiene is performed before and after patient contact, contact with patient environment, between patients and before and after gloving."

According to the facility's policy "Hand Hygiene Policy," dated 11/1/2023, the policy revealed that indications for hand hygiene are "Between clean and contaminated tasks on the same patient "and "After contact with equipment or surfaces likely to be contaminated, including bed rails, bedside trays, telephones, and other objects in the patient's immediate environment." The policy also revealed that "Gloves are never a substitute for hand hygiene" and "Gloves are changed after each task."