HospitalInspections.org

Based on hospital document review, medical record review and interview, nursing services failed to assess and document surgical incision sites and/or surgical dressings for 2 of 3 (Patient #1 and #3) sampled post operative patients reviewed.

The findings included:

1. Review of the hospital's "Focused Assessment" education document revealed, "...A focused assessment is a detailed nursing assessment of a specific body system, or several body systems, relating to the presenting problem or current concerns of the patient... Another type of nursing assessments is a shift assessment, a concise nursing assessment completed at the beginning of each shift... Procedures... Integumentary System 1. Inspect the patient's skin for scars, lesions, wounds, redness, or irritation... Documentation... Integumentary System... Inspection findings (presence of scars, lesions, wounds, redness, or irritation)..."

Review of the hospital's "Postoperative Care" education document revealed, "...Nursing care of a postoperative patient is divided into two phases: immediate recovery (phase I) and postoperative care (phase II). During both phases, the nurse makes comprehensive, detailed assessments of the patient's condition...The phase II recovery period extends from the time a patient is transferred to the designated nursing unit after becoming stable in the phase I recovery area to the time the patient is discharged home..."

3. Medical record review for Patient #1 revealed an admission date of 5/28/2023 with diagnoses which included a Closed (a closed fracture is a broken bone with the skin still intact.) Intertrochanteric Fracture (a intertrochanteric hip fracture occurs three to four inches from the hip joint) of the Left Hip, Fall with Injury, Hyponatremia (low sodium level in the blood) , Hypertension, Osteoarthritis and Osteoporosis.

Review of the Surgical Documentation dated 5/30/2023 revealed Patient #1 had an Open Hip Reduction (in this type of surgery, the hip joint is opened up to clear out any tissue that is keeping the head of the ball from going back into the socket) and Repair of the Left Hip completed with no complications documented. Patient #1 remained in the hospital until 6/6/2023.

Review of the nursing documentation dated 5/30/2023 through 6/6/2023 revealed the patient's "Incision/Wound Dressing...Condition" was assessed on 5/30/2023 at 5:40 PM, 6/3/2023 at 8:00 AM, and on 6/5/2023 at 8:00 PM. There was no other documentation Patient #1's surgical incision site and/or dressing was assessed by nursing staff.

4. Medical record review for Patient #3 revealed an admission date of 10/11/2023 with diagnoses which included a Left Subcapital Hip Fracture (fracture that occurs in the neck of the thighbone), Head Trauma with Left Facial Laceration, Dehydration, Leukocytosis (high white blood cell level in the blood), Possible Urinary Tract Infection and Hypertension.

Review of the Surgical Documentation dated 10/12/2023 revealed Patient #3 had an Open Hip Reduction with Lag Screw (a type of screw used to compress fracture fragments) Placement completed with no complications documented. Patient #3 remained in the hospital until 10/17/2023.

Review of the nursing documentation dated 10/12/2023 through 10/17/2023 revealed the patient's "Incision/Wound Dressing...Condition" was only assessed by nursing staff on 10/17/2023 at 8:00 AM. There was no other documentation Patient #1's surgical incision site and/or dressing was assessed by nursing staff.

5. In an interview on 10/18/2023 at 9:20 AM, the Unit Manager for the units where Patients #1 and #3 were housed during their hospitalization was asked how often surgical incision sites and/or surgical dressings should be assessed by a nurse. The Unit Manager stated, "Q [every] shift. They should document either the incision site or the condition of the dressing."

Based on policy review, observation and interview, the hospital failed to ensure infection control measures were followed by 1 of 2 (Registered Nurse [RN] #2) RNs observed performing patient care in the Post Anesthesia Care Unit (PACU).

The findings included:

1. Review of the hospital's "Hand Hygiene" policy effective on 5/26/2021 revealed, "...The purpose of this policy is to outline hand hygiene requirements to reduce the risk of infection transmission from patient to patient, patient to healthcare provider, and healthcare provider to patient..."Hand Hygiene" means hand washing, antiseptic hand wash, antiseptic hand rub or surgical antisepsis...The Hospital's policy is to adopt the CDC [Centers for Disease Control] Guidelines with enhancements from WHO [World Health Organization] Guideline...Indications for handwashing and hand antisepsis...Before direct patient contact...After removing gloves...After contact with inanimate objects or medical equipment close to patient...Before handling medication or food..."

2. Observations in the PACU on 10/18/2023 beginning at 12:00 PM revealed RN #2 was setting up patient equipment anticipating the arrival of Patient #4 from the operating room following a right knee arthroplasty (total knee replacement). The RN cleaned all reusable items with Sani-cloth antiseptic wipes and allowed the objects to air dry. RN #2 removed his gloves, performed hand hygiene and walked to the nurses' station, leaned over and rested his outstretched arms directly on top of the counter. At 12:10 PM, Patient #4 was brought into the area on a stretcher and moved to the area prepared for his arrival. Without performing hand hygiene or donning gloves, RN #2 assumed care of the patient and connected the cardiac monitor, and pulse oximetry. The RN removed the covers from the patient's right leg exposing the surgical dressing and attached surgical drain. The RN donned gloves without performing hand hygiene, removed the nasal trumpet from the patient's nose and handed it to one of the operating room staff. RN #2 applied a leg brace to the patient's right lower leg and connected the cooling pump. RN #2 removed his gloves, obtained a new set of oxygen tubing with nasal cannula, opened it and laid the tubing on the patient's chest. Without performing hand hygiene, the RN donned new gloves, put the nasal cannula in place on the patient and connected the tubing to the oxygen supply. Patient #4 reached up and held onto RN #2's gloved hand for a brief second, then let go of the nurse's hand. RN #2 removed the gloves, picked up the patient's medical chart, performed hand hygiene and walked to the nurses' station and used the phone to call the patient's spouse. After the phone call was completed, the nurse walked back over to Patient #4's bedside, placed the medical chart on the over bed table, then prepared a cup of ice water for the patient. RN #2 opened and placed a straw into the cup and took it to Patient #4 and held it for him to drink. After the patient drank some water, the RN placed the cup onto the table and sat down at the computer and began documenting into the electronic medical record. At 12:35, RN #2 stood up, donned gloves without performing hand hygiene, and assessed the patient's lower extremities for sensation, pulse and strength. RN #2 removed the gloves, adjusted the intravenous (IV) fluid drip rate, performed hand hygiene and continued his documentation in the electronic medical record. RN #2 was off the unit and out of eyesight of the surveyor from 1:04 PM until 1:08 PM. The RN returned to the area holding graham crackers and juice. RN #2 donned gloves, handed the patient the juice and crackers and began disconnecting the patient from the cardiac monitor and pulse oximetry. The RN placed the bag of intravenous (IV) fluid onto the bed beside the patient, disconnected the oxygen tubing from the oxygen supply and connected it to a portable oxygen tank then placed the cooling unit on the patient's bed. Together with another staff member, RN #2 lifted the bed rails and began moving the patient's bed out of the unit headed for the orthopedic unit. Upon arrival at the patient's assigned room, the RN noticed there was already a clean hospital bed in the room. RN #2, while still wearing the same gloves, entered the room, placed his hands on the bedrails of the other hospital bed and moved the bed out into the hallway, then moved Patient #4 into the room. The RN disconnected the oxygen tubing from the portable tank, connected it to the oxygen supply and placed the cooling unit on the floor beside the patient's bed while the other staff member hung the bag of IV fluid on the IV pole. At 1:25 PM, RN #2 and the other staff person exited the patient's room. The other staff member performed hand hygiene before exiting the patient's room; however, RN #2 kept his gloves on and began rolling the other hospital bed he had placed in the hallway off the unit. When the RN was about to exit the unit, he removed his gloves and performed hand hygiene.
RN #2 failed to perform hand hygiene before and after glove use repeatedly.

3. In an interview on 10/18/2023 at 1:30 PM, the Director of Quality Improvement and Risk Manager verified hand hygiene is expected to be performed before and after patient care and before and after glove use.

Based on policy review, observation and interview, the hospital failed to ensure measures to decrease the transmission of potentially infectious materials were maintained in 1 of 3 (3 North) patient care areas observed.

The findings included:

1. Review of the hospital's "Cleanup Of Body Fluid Spills" policy effective 5/21/2021 revealed, "...The purpose of this policy is to prevent the transmission of disease from infectious waste spills...Blood, Body Fluids or Infectious Material Spills 1. Towel Clean-Up Procedure a. Don non-sterile gloves...Wipe up spill with paper towel or linen towel...Disinfect area with EPA [Environment Protection Agency] approved disinfectant or bleach solution...Contact Environmental Services Department to complete cleaning procedure..."

Observations outside patient room #324 and #326 on 10/17/2023 at 4:27 PM revealed 5 drops of a shiny, dark red substance on the floor between the 2 patient rooms. One of the drops appeared to have been smeared slightly.

Observations outside patient room #324 and #326 on 10/18/2023 at 9:10 AM revealed the 5 drops observed on 10/17/2023 were still on the floor but were no longer shiny.

In an interview on 10/18/2023 at 9:11 AM, RN #1 was asked what the dark red drops on the floor were. The RN stated, "It looks like blood."

In an interview on 10/18/2023 at 10:08 AM, the Assistant Director of Environmental Services (ASEVS) was asked how often the floors in the patient care areas were mopped. The ASEVS stated, "The morning [staff] refreshes and does the floor. We have a floor tech that usually does the heavy cleaning at night; I think he [floor tech] was off last night."