HospitalInspections.org

Based on medical record review, policy review and staff interview, it was determined that staff failed to document nursing assessments and patient care for 2 of 5 patients (Patient #'s 1 and 3) in the sample. Findings included:

The hospital policy entitled "Pain Management" stated, "...right to optimal pain management through appropriate assessment documentation...following factors will be included in that assessment...Intensity (0-10 scale) or use of non-verbal assessment tool...Location...Pain assessments/reassessments and interventions will be documented..."

The hospital policy entitled "Documentation: Multidisciplinary Adult Medical, Surgical and Pediatric" stated, "Patient care will be documented...document the care process and the provision of individualized goal-directed care. The components of the approach are assessment, problem identification, intervention and evaluation..."

The hospital's "Skin Care: Pressure Ulcer Prevention Guidelines" entitled "High Risk Pressure Ulcer Prevention Guidelines" stated, "...Braden Score (scale used to assess level of risk for development of pressure ulcers) 6-14...Turn patient at least every 2 hours while in bed and document in the patient's permanent medical record..."

Medical record review revealed:

A. Patient #1

1. "Medication Administration Record" documentation by the registered nurse (RN) failed to include the following pain assessment information:

a. Location and intensity of pain:

2/28/14 at 11:07 PM
3/1/14 at 4:44 PM
3/2/14 at 4:46 PM
3/3/14 at 8:41 AM and 4:41 PM
3/6/14 at 9:02 AM
3/15/14 at 6:24 PM
3/16/14 at 8:57 AM
3/18/14 at 12:28 PM
3/19/14 at 4:13 AM
3/21/14 at 8:08 PM
3/24/14 at 5:13 AM
3/26/14 at 1:56 PM
4/5/14 at 3:58 PM
4/27/14 at 12:26 PM
5/5/14 at 4:45 AM
5/18/14 at 12:19 PM
5/19/14 at 12:30 PM
5/21/14 at 5:14 AM

b. Location of pain:

3/9/14 at 4:58 PM
3/11/14 at 8:27 AM
3/12/14 at 10:18 AM
3/27/14 at 5:39 PM
4/3/14 at 9:13 AM and 5:49 PM
4/6/14 at 3:26 PM
4/9/14 at 7:38 AM and 3:53 PM
5/3/14 at 9:32 AM
5/6/14 at 6:36 PM
5/13/14 at 11:56 PM
5/14/14 at 9:39 AM
5/18/14 at 11:07 AM

c. Intensity of pain:

3/10/14 at12:47 AM
3/17/14 at 8:42 PM
3/26/14 at 8:34 PM
3/27/14 at 10:18 AM
3/29/14 at 4:26 PM
3/31/14 at 2:47 PM
4/10/14 at 11:03 PM
4/11/14 at 12:48 PM
4/12/14 at 5:35 PM
4/13/14 at 10:31 AM
4/15/14 at 8:55 AM
4/25/14 at 8:42 PM
5/2/14 at 3:07 PM
5/4/14 at 12:01 PM
5/13/14 at 2:39 PM

RN F reviewed the medical record for pain assessment documentation on 8/12/14 between 10:45 AM - 12:45 PM and 1:30 PM - 4:28 PM and on 8/13/14 between 2:40 PM - 3:36 PM and confirmed that nurses:

- failed to ensure that pain assessment documentation included the location and/or intensity of the patient's pain

B. Patient #3

1. The 8/9/14 "Adult Systems Assessment" revealed that Patient #3:
- required complete assistance with activities of daily living, including bed mobility
- had a Braden Score of "13" (moderate risk for pressure sore development)

2. No documented evidence that Patient #3 was turned and/or repositioned every two hours during the following time periods:

8/10/14 2:24 AM - 10:00 AM (over 7 hours)
12:55 PM - 11:59 PM (11 hours)

8/11/14
12:00 AM - 6:00 AM (6 hours)
8:00 PM - 12:25 PM (over 4 hours)

RN E reviewed the medical record on 8/14/14 at 4:45 PM and confirmed these findings.

Based on observation, policy review, job description review and staff interview, it was determined that for 3 of 3 patient observations (Patient #'s 1, 2 and 3), registered nurses (RNs) failed to follow the hospital's policy for infection control. Findings include:

The hospital job description entitled "Coordinator Infection Prevention" stated, "...Ensures regulatory compliance...Responsible for the area of infection prevention, control...systematic process to ensure continuity of care...and control of infection..."

The hospital policy entitled "Hand Hygiene Practices for the Prevention of Infection" stated, "...Hand hygiene...Decontaminate hands before direct contact with patients...after contact with patient's intact skin...if moving from a contaminated body site to a clean body site during patient care...after contact with inanimate objects in the immediate vicinity of the patient...after removing gloves..."

The hospital policy entitled "Gowning, Masking and Gloving Techniques" stated, "...Gowning Techniques...Select Gown...Fully cover torso...wrap around back...Fasten at neck and waist...Complete patient care...Remove gloves properly to prevent hand contamination...Perform hand hygiene and unfasten gown at neck and waist...Perform hand hygiene before leaving room..."

A. Patient #1

1. Medical record review revealed:

a. The sacral (lower back) wound culture final report, dated 7/13/14 at 9:24 AM, revealed the following:

- Methicillin-resistant Staphylococcus aureus (MRSA - a contagious and antibiotic-resistant bacteria)
- Vancomycin-resistant enterococci (VRE - bacteria resistant to many antibiotics)
- pseudomanas aeruginosa (bacterial infection)
- result comments for the MRSA and VRE included "Hospital inpatients require special contact precautions"

b. Physician's orders for patient isolation and contact precautions as follows:

- 7/9/14 at 2:19 AM: for MRSA
- 7/13/14 at 11:19 AM: for VRE

2. On 8/14/14 between 9:25 AM and 9:43 AM, RN A was observed providing the following patient care:

- sanitized hands
- donned isolation gown, tied gown at neck
- donned gloves
- administered intravenous (IV) medication
- removed gloves
- donned gloves
- administered eye drops
- removed gloves
- donned gloves
- repositioned patient in bed
- removed isolation gown
- removed gloves
- wiped down medication cart with a disinfectant wipe
- exited isolation room
- washed hands

RN A failed to:
- secure the isolation gown at the waist
- perform hand hygiene after glove removal
- perform hand hygiene before leaving isolation room

During an interview on 8/14/14 at 11:30 AM, Infection Preventionist A confirmed that the observed practice did not conform to the hospital's infection prevention policy for hand hygiene or use of personal protective equipment.

B. On 8/12/14 at 11:45 AM, the following was observed during the care provided to Patient #2 by RN B:

- sanitized hands
- donned gloves
- administered medication
- removed gloves and discarded gloves
- returned to patient
- touched bed
- touched patient's face
- retrieved oral hygiene swabs from wall mounted container
- connected swab to suction tubing at patient bedside
- touched patient's face and arm

RN B failed to perform hand hygiene:
- after contact with inanimate objects
- prior to and after direct patient contact
- after removing gloves

C. On 8/12/14 at 12:00 PM, the following was observed during the care provided to Patient #2 by RN C:

- sanitized hands
- donned gloves
- assisted RN B to turn patient to left side
- touched patient's buttocks
- walked to closed wall cabinets
- open cabinets
- retrieved cleansing wipes and lotion
- returned to patient
- cleansed buttocks with wipes
- applied lotion to buttocks and peri anal area
- removed gloves
- donned new gloves
- touched patient
- placed clean sheet on patient

RN C failed to perform hand hygiene:
- prior to and after direct patient contact
- after removing gloves
- after contact with inanimate objects

Interview on 8/14/14 at 10:10 AM with Infection Preventionist A revealed that the observed practice did not conform to the hospital's infection prevention policy for hand hygiene.

D. On 8/12/14 between 3:25 PM and 3:35 PM, the following was observed as RN D administered medication to Patient #3:

- sanitized hands
- obtained new IV medication bag from medication cart
- disconnected previously administered IV medication bag from tubing
- attached new IV medication to IV tubing
- hung new IV medication on IV pole
- left patient bedside
- obtained trash can
- donned gloves
- returned to Patient #3
- disconnected IV tubing at patient's access site
- touched syringe and IV tubing
- obtained alcohol pad
- disinfected hub of patient's IV access site
- connected IV tubing to patient's IV access site
- started IV administration
- removed gloves
- sanitized hands

RN D failed to perform hand hygiene:
- after contact with inanimate objects in patient area
- before direct patient contact

Interview on 8/14/14 at 9:10 AM with Infection Preventionist A revealed that the observed practice did not conform to the hospital's infection prevention policy for hand hygiene.