HospitalInspections.org

Based on record review and interview, the registered nurse failed to supervise and evaluate the care provided to patients by failing to thoroughly assess a wound for 1 of 1 patient admitted with a wound (#3) in a total sample of 20.
Findings:

Review of Patient #3's electronic medical record with S3LPN revealed an acute care admit date of 02/06/20. Review of the RN admit assessment dated 02/06/20 revealed the patient had a blister noted to the left heel. There was no assessment of the size or color.

Review of a physician order dated 02/07/20 revealed an order to consult physical therapy for wound to the patient's left heel. Review of the assessment by physical therapy dated 02/07/20 revealed a bruised area to the left heel. There was no assessment of the size or color or the bruise. Physical Therapy did not recommend any orders for dressing changes.

Review of the daily nursing assessments dated 02/08/20, 02/09/20 and 02/10/20 at 7:30 a.m. revealed the patient had "left heel bruise/open wound" to the left heel and that the dressing was dry and intact.

Review of the swingbed admit nursing assessment dated 02/10/20 at 10:30 a.m. (3 hours after the previous assessment) revealed that the patient had a blister to the left heel. There was no assessment of the size or color. Review of the subsequent nursing assessments dated 02/10/20 at 7:00 p.m. and 02/11/20 at 7:10 a.m. revealed the patient had a blister to the left heel.

On 02/11/20 at 3:00 p.m., interview with S3LPN confirmed that there was no documented evidence of a thorough assessment of the patient's wound to the left heel. S3LPN further confirmed that the patient had no physician orders for dressing changes and that she was unsure why the nurses were documenting that the dressing was dry and intact.

Based on record review and interview, the CAH failed to ensure the nursing staff developed, and kept current, a comprehensive nursing care plan based upon ongoing assessments of patients' needs. This deficient practice was evidenced by failure to ensure patient care plans were inclusive of all medical diagnoses for 3 (#3, 13, 14) of 14 (#1-#14) sampled patients reviewed for care plans from a total patient sample of 20.
Findings:

Review of the hospital policy titled, "Comprehensive Care Plans", Document Number 601.NSG.906, revised 07/26/2016 revealed in part: I. Purpose: To assure that a complete view of the patient's needs and treatments are being completed in a timely manner. Procedure: A comprehensive care plan is developed for each patient that includes measureable objectives and timetables to meet a patient's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Patient #3
Review of the electronic medical record for patient #3 revealed an admission date of 02/06/2020 with diagnosis including Pneumonia and COPD.

Review of the nursing assessment dated 02/06/2020 revealed the patient had a wound to the left heel.

Review of the care plan for patient #3 revealed no identified problems addressing the patient's wound.

Interview on 02/12/2020 at 10:50 a.m. with S3LPN confirmed patient #3's care plan was not individualized to include the patient's wound.

Patient #13
Review of the electronic medical record for patient #13 revealed an admission date of 11/20/19 with diagnosis of CHF, Diverticulitis and hypertension.

Review of the physician's orders dated 11/20/19 revealed medication orders for Toprol XL 50 mg PO q day, Norvasc 10 mg PO q day, Cozaar 50 mg PO q day, and Catapress 0.1 mg PO q eight hours prn.

Review of the care plan for patient #13 revealed problems identified abdominal pain and diverticulitis. There were no identified problems to address the patients CHF and hypertension.

Interview on 02/12/2020 at 1:20 p.m. with S2CM confirmed patient #13's care plan was not individualized to address problems with CHF and hypertension.

Patient #14
Review of the electronic medical record for patient #14 revealed an admission date of 10/03/19 for Antibiotic therapy and wound care, with diagnosis of Hypothyroidism, GERD, hypertension and Cellulitis.

Review of the physician's orders dated 02/09/2020 revealed orders for Levothyroxine 0.025 mg PO q day, and Metoprolol Succinate 12.5 mg PO BID.

Review of the care plan for patient #14 revealed there were no problems identified to address the patient's wounds, hypothyroidism, GERD, hypertension and cellulitis.

Interview on 02/12/2020 at 1:50 p.m. with S2CM confirmed patient #14's care plan was not individualized.

20310

I. Based on observation, record review and interviews, the CAH failed to maintain a clean and sanitary environment to avoid sources of infection in the Endoscopy processing area, as evidenced by:
1) failing to monitor the temperature of the high level disinfectant solution;
2) failing to properly mix and dilute the enzymatic cleaning solution according to the manufacturer's instructions;
3) using expired cleaning and disinfecting solutions;
4) failing to properly conduct a leak test prior to the cleaning procedure;
5) failing to properly dry scopes with alcohol flush and forced air prior to hanging to dry;
6) failing to allow scopes to hang freely in a vertical position in the scope cabinet;
7) failing to have adequate ventilation in the scope cabinet, and;
8) failing to ensure that the Endoscopy Department was included in infection control surveillance and QA monitoring.
Findings:

Review of the current policy and procedure guidelines for endoscope processing presented by S4QA revealed, in part, the following:
Guideline for policies:
Recommended Guidelines for Infection Control in Gastrointestinal Endoscopy Settings by the Society of Gastroenterology Nurses and Associates.
Pages 2, 3: Recommendations for Endoscopes:
-Inspection - Leak testing should be performed prior to the cleaning process.
-Disinfection - When used according to manufacturer's instructions, a high level disinfectant destroys all microorganisms but not necessarily all bacterial spores. The chemical agent should be sporicidal when used in recommended concentrations and at specified temperatures.
-Rinsing - If tap water is used, follow with a 70% alcohol rinse and dry with compressed air.
-Drying - Dry the insertion tube and inner channels thoroughly using forced air after cleaning/disinfection and prior to storage. Bacteria and fungi multiply in a moist environment. Prior to storage, flush the channels with 70-90% ethyl or isopropyl alcohol to facilitate drying of the channel and discourage growth of residual bacteria and fungi. The alcohol rinse and drying procedure must be performed prior to endoscope storage.
-Storage - Endoscopes must be stored in a way that prevents recontamination or damage between uses. They should be hung vertically in a well-ventilated cabinet.
Presented as guideline for protocols:
Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008:
In general, endoscope disinfection or sterilization with a liquid chemical sterilant involves five steps after leak testing:
1. Clean: ...(leak testing is recommended for endoscopes before immersion)
4. Dry: rinse the insertion tube and inner channels with alcohol, and dry with forced air after disinfection and before storage.
Store: store the endoscope in a way that prevents recontamination ad promotes drying (hung vertically) ...Drying the endoscope (step 4) is essential to greatly reduce the chance of recontamination of the endoscope by microorganisms that can be present in the rinse water.
Page 4 ...Leak Testing - The first step is cleaning and flushing at the procedure site. The second step of reprocessing a flexible endoscope involves leak testing.

On 2/11/20 at 9:00a.m., observation of the decontamination and scope processing room with S3LPN, Endoscopy Nurse, revealed several scopes hanging in the clean scope cabinet. The tubing of some of the scopes was curled and touching the surface of the drip cloth sitting on the floor of the cabinet, which prevented the scopes from hanging freely. Further, the cabinet was closed with no ventilation to allow air flow into the cabinet. An interview at this time with S3LPN, Endoscopy Nurse, confirmed the positioning of the scopes could allow water to sit inside the bottom of the tubing and harbor bacteria. When questioned about the procedures followed for the decontamination of the endoscopes, S3LPN confirmed she did not do scope processing and was not familiar with the procedure.

On 2/12/20 at 8:43 a.m., an observation and interview was conducted with S6ST, who explained her procedure for processing of scopes -
She starts out by filling a large container with 3 gallons of McKesson OPA/28 high level disinfectant (may use up to 28 days); if not a new fill, she uses the test strips to check pass or fail and documents results on a log. She stated there are no measures in place to monitor the temperature of the solution and confirmed that it is used for 28 days unless it fails the strip test. Review of the manufacturer's label for the disinfectant revealed it should be stored in a manner to maintain the temperature between 59 - 77 degrees Fahrenheit.
Next, she stated she puts enough water into the sink to cover the scope (no measured fill line noted), then adds some of the Valsure Enzymatic Cleaner and Endozime Xtreme Power super concentrate enzymatic detergent to the water. She stated she does not measure the water placed in the sink or the amount of either of the detergents. Review of the manufacturer's label for the Valsure Enzymatic Cleaner revealed instructions to mix ½-1 ounce of the solution to each gallon of water.
Further observation of the available supply of cleaning solutions revealed an opened container of Endozime Xtreme Power expired in May 2019, an opened container of Valsure expired in December 2019 and an unopened container of Valsure expired in April 2019.

Further interview regarding the drying process revealed she removes the scopes from the high level disinfectant soak, rinses them, and lays them flat on a towel on the countertop to dry. Interview regarding the leak test procedure revealed she does a leak test at the end of the processing by taking the scope to the recovery room, attaching it to the oxygen on the wall and using a soap solution to test for leaks. She then rinses the scope and returns it to the towel on the countertop to lay flat and dry. When the outside of the tubing is dry, she dumps the water from the head of the scope and hangs the scope in the cabinet to finish drying. She confirmed that she does not use any process to force air or alcohol through the scope prior to hanging to dry.

On 02/12/2020 at 11:00 a.m., review of the infection control program and QA data with S5ICO and S4QA revealed no documented evidence of surveillance and monitoring of infection control concerns in the Endoscopy department. S5ICO and S4QA confirmed there was no surveillance and monitoring of infection control concerns within the Endoscopy department.

II. Based on observation and interview, the CAH failed to maintain a clean and sanitary environment to avoid sources of infection by failing to ensure expired supplies were not available for patient use.
Findings:

On 02/10/2020 at 9:30 a.m., observation of the nursing supply room revealed the following expired supplies:
22 french Foley catheter, expired 08/2019
20 french Foley catheter, expired 01/31/20
20 french Foley catheter, expired 12/2019
26 french Foley catheter, expired 12/2019
(2) Multi lumen central venous catheter trays, expired 09/30/19
6 packages of Elasto-gel wound dressings expired 09/19
6 packages of Vaseline petro gauze strips expired 03/19, 4 packages expired 09/19
4 packages of size 6 ½ sterile surgical gloves expired 12/19

On 02/10/2020 at 10:20 a.m., interview with S1DON confirmed that the above expired supplies were available for patient use.

On 02/11/2020 at 8:30a.m., a tour of the Endoscopy procedure room with S3LPN, Endoscopy Nurse revealed the following:
Two unlabeled 60cc syringes with clear liquid were noted lying underneath a drape on top of a piece of equipment, dated 12/18/19. S3LPN stated it was probably sterile water, and should have been discarded after the procedure on 12/18/19. Further observation revealed 2 opened and undated bottles of sterile water on the bottom of the equipment cart. S3LPN confirmed the undated, opened bottles should not be available for patient use and should have been discarded.