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Based on interview and record review, the facility failed to ensure that ordered pressure injury prevention interventions were consistently incorporated into nursing care plans and consistently implemented, for one (Patient #1) of three patients reviewed for wounds out of a total sample of 11, resulting in the development of a Stage III - IV Pressure Injury.

On 1/4/17 at 1000, a review of the medical record for the patient of concern (#1) was conducted and revealed the following information:

Patient #1 was a 78 year old male who was originally admitted to the facility on 5/23/17 through 5/29/17 for admitting diagnoses of elevated troponin levels (heart problems) and Closed Fracture of the right hip. Diagnoses at that admission included Diabetes Mellitus II, Encephalopathy, Ischemic Heart Disease, Pacemaker, Pancreatic Lesion/Mass/Suspected Pancreatic Cancer, and Mechanical Loosening of Internal Prosthetic Joint. Patient #1 had surgery on 5/25/17 to repair the broken right hip and replace damaged parts of the right prosthetic hip joint.

Physician's orders for Patient #1 included the following pressure relieving interventions, dated 5/23/17, and active until 5/29/17; a pressure relieving air mattress, and, "turn and reposition every two hours (q2) while in bed." Review of daily Nursing Care plans for Patient #1 from 5/23/17 through 5/29/17 revealed an intervention for Skin Integrity included the intervention, Turn and Reposition Q2 while in bed. There was no intervention noted in the nursing care plan for the level of staff assistance needed to assist the patient in turning and repositioning.

Physician's Progress notes, Physical Therapy (PT), Occupational Therapy (OT) and Case Management notes from 5/25/17 through 5/29/17 described Patient #1 as confused. PT and OT assessments and Progress notes from 5/25/17 through 5/29/17 documented that Patient #1 had memory problems, confusion, impaired bed mobility (ability to turn and reposition), and needed maximum assistance (was dependent) from two staff members (max assist x 2) for mobility in bed. Review of Nursing flow sheets for Patient #1 from 5/25/17 through 5/29/17 revealed documentation that Patient #1 was not regularly repositioned per physician's orders and Nursing Care Plan (q2 while in bed) from 5/26/17 through 5/29/17, and included Nursing notations that Patient#1 was independent for repositioning, in contradiction to PT and OT assessments of Patient #1. A suspected pressure injury on Patient #1's coccyx was observed during a nursing admission assessment on 5/29/17 at 1500, after the patient was transferred to the Acute Care Rehab Unit.

Patient #1 was identified as having a pressure injury on his coccyx after his transfer to the Acute Care Rehabilitation Unit on 5/29/17. A Nursing Admission documentation dated 5/29/17 at 1500 documented that Patient #1 had a Deep Pressure Injury (discolored area without broken skin) measuring 3 cm (centimeters) by 0.5 cm wide by 0 cm deep on his coccyx on admission to the Acute Care Rehab Unit. PT and OT assessments continued to document that Patient #1 had impaired ability to turn and reposition in bed without staff assistance. Physician's orders for pressure relief included an order dated 5/29/17 at 1900, "Turn and reposition q2 when in bed", which was active until discharge on 6/13/17. Nursing Care Plans from 5/29/17 through 6/13/17 documented a skin integrity intervention to turn and reposition the patient q2 when in bed. There was no nursing care plan notation of the level of assistance Patient #1 needed for bed mobility. Nursing flow sheets continued to document that Patient #1 was independent for bed mobility in contradiction to PT and OT assessments, and q2 staff assisted repositioning was not documented as done. The Physician's Discharge Summary dated 6/13/17 at 1111, documented that Patient #1's sacral wound was an infected Stage III decubitus (pressure injury with full thickness skin loss) at discharge to the Acute Care Hospital on 6/13/17.

An Acute Care Infectious Disease Consultation Report dated 6/19/17 documented that microbial cultures of the pressure wound on Patient #1's coccyx was positive for infection with Staphylococcus aureus and Candida albicans (fungus). The report noted, "Acutely infected coccygeal ulcer with purulent drainage, tenderness and redness." The report documented the infected coccygeal ulcer as Stage III or IV (exposing muscle, fascia or bone). Physician's orders for pressure injury prevention dated 6/14/17, and active until discharge on 6/28/17 included, "turn and reposition q2 when in bed", and "elevate heels off of bed." PT and OT assessments and progress notes from 6/15/17 through discharge on 6/28/17 continued to document that Patient #1 was confused, lethargic, had difficulty following directions, and needed moderate to maximum assistance from two staff for turning and repositioning in bed. Nursing Care plans for skin integrity contained interventions to turn and reposition q2 and elevate heels when in bed, but there was no documentation to indicate this was consistently implemented. Nursing flowsheets from 6/13/17 through 6/28/17 did not document that Patient #2 was repositioned q2 while in bed from 6/13/17 through discharge on 6/28/17, or had his heels consistently elevated until he developed a heel deep tissue injury on 6/20/17. The reviewed Nursing flowsheets documented that Patient #1 was independent for bed mobility, in contradiction to PT and OT assessments. Patient #1 developed an additional pressure injury, a Deep Pressure Injury to the right heel on 6/20/17.

Review of a Discharge Summary dated 6/28/17 at 1111, documented that Patient #1 diagnoses at discharge included infected prosthesis, Stage III Sacral Decubitus, Cellulitis of Right Hip - improved, Acute on Chronic Anemia, and Metabolic Encephalopathy with likely underlying Dementia. The Discharge Summary noted that there was soft tissue infection of the coccyx.

On 1/4/17 at approximately 1400, Staff A, the facility Safety and Quality Director, Staff A, and the Chief Nursing Officer, Staff C were interviewed regarding Patient #1's Pressure injury, and were unable to provide any additional documentation to indicate that Nursing Care Plans were updated as necessary to provide sufficient guidance to nursing staff regarding Patient#1's needed level of staff assistance in turning and repositioning in bed, or documentation to indicate that ordered and careplanned interventions to prevent pressure injury were consistently implemented for Patient #1. Staff C stated, "There's a problem with communication between the different disciplines with (the electronic medical record system). There wasn't communication between therapy and nursing (for Patient #1)."

Based on observation, interview and record review the facility failed to ensure hospital infection control policies were implemented during nursing care observations for two (#'s 3 and 9) of two patients observed during nursing care, and for one (#1) of three closed records reviewed for wound infections from a total sample of 10 patients reviewed, resulting in the risk of transmission of infectious and/or communicable diseases. Findings include:

On 1/4/18 at 0830 Registered Nurse, Staff K was observed during a medication administration for patient #9. Staff K was outside patient 9's room with her medication cart. Staff K was not observed to perform hand washing or hand hygiene prior to removing patient # 9's medications form the medication cart, or prior to removing an open multi-dose bottle of Humalog insulin from the cart. Staff K was then observed to puncture the diaphragm of the insulin vial with a needle and draw 4 units of insulin into a syringe. Staff K did not disinfect the access diaphragm of the insulin vial prior to entering it with the needle. Staff K then entered the patients room without performing hand washing or hand hygiene and opened a package containing a pre-filled Lovenox syringe (injectable anticoagulant), then opened patient # 9's oral medications and placed them into a cup. Staff K provided privacy with the patient curtain, identified the patient, donned gloves and injected the Lovenox into patient #9's abdomen, and removed the gloves. Staff K did not perform hand hygiene before or after donning and removing the gloves. Staff K then handed patient #9 the cup with the oral medications and the patient took the medications with water. Staff K did not give the insulin injection to the patient due to the patient had not eaten breakfast as yet. Staff K opened the privacy curtain, discarded the insulin syringe into a sharps container, documented in the computer and exited the room. Staff K did not perform hand hygiene after exiting the patient's room.

On 1/4/18 at approximately 0840 Staff K was queried about the lack of hand hygiene and cleaning of the insulin vial diaphragm as noted in the above observations. Staff K stated "I did not wash or sanitize my hands, I should have. I should have cleaned the vial with alcohol before drawing up the insulin." Staff K was then observed to sanitize her hands.

On 1/4/18 at 1305 the facility Chief Nursing Officer, Staff C was informed of the above noted observations. Staff C stated she had been informed of the infection control lapses noted above. Staff C provided copies of the facility infection control policies for hand hygiene and multi dose vials.

On 1/4/18 at 1310 the following infection control policies were reviewed:

Infection control policy number 407, titled "Hand Hygiene" dated reviewed 8/2017 documented the following: "Objective: Hand Hygiene is the single most important measure for preventing the spread of infection. . .Employees will use proper hand hygiene: 1. Upon entering and exiting any patient room. 2. Before and after contact with patient's intact skin. 3. After contact with environmental surfaces in the immediate vicinity of the patients. . .4. After glove removal. . .

Policy number 414, titled "Multi Dose Vials" documented "Objective: To minimize the risk that multi-dose containers will be a source of infection/colonization with microorganisms. Scope: Multi dose medications containers may be the source of infection. 1. Must follow the requirements of the policy. 2. It is the responsibility of each person using a multiple-does vial to determine its safety for future use based on any suspected or known compromise to the solution's sterility. Procedure: . . .c. Cleanse the access diaphragm of the multi-does vials with 70% alcohol (such as alcohol swabs) before inserting a devices into the vial then allow to dry."


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On 1/4/17 at 1000, a review of the medical record for the patient of concern (#1) was conducted and revealed the following information:

Patient #1 was a 78 year old male who was originally admitted to the facility on 5/23/17 through 5/29/17 for admitting diagnoses of elevated troponin levels (heart problems) and Closed Fracture of the right hip. Diagnoses at that admission included Diabetes Mellitus II, Encephalopathy, Ischemic Heart Disease, Pacemaker, Pancreatic Lesion/Mass/Suspected Pancreatic Cancer, and Mechanical Loosening of Internal Prosthetic Joint.

Patient #1 had surgery at the facility on 5/25/17 to repair the broken right hip and replace damaged parts of the right prosthetic hip joint.

Review of Physician's orders for Patient #1 from 5/23/17 through discharge on 5/29/17, revealed Patient #1 had a "Wound Vac" (negative pressure wound therapy) with a specialized wound vac dressing on the right hip surgical incision (to remove wound drainage) from 5/25/17 through discharge on 5/29/17. The wound vac remained in place through the patient's final discharge and transfer to a SNF on 6/28/17. Review of Nursing flow sheets for Patient #1 from 5/25/17 through 5/29/17 documented that the patient's surgical site dressing (specialized wound vac dressing was assessed each shift, with no signs of wound infection noted until after transfer to the Acute Care Rehab unit.

On 1/4/18 at approximately 1000, review of a facility Incident Report and investigation dated 5/30/17, labeled, "Inappropriate Treatment", documented that Patient #1's wound vac was not functioning due to a broken power cord on 5/30/17 at 0236, approximately 12 ½ hours after Patient #1 was transferred to the Acute Care Rehab unit. The incident report noted that, per the midnight Nursing Supervisor's advice, Nursing staff failed to follow facility policy for wound care. They replaced Patient #1's wound vac dressing with an unapproved (wet to dry) dressing in violation of facility policy, and without consulting the surgeon. The incident report documented this as a risk for surgical site infection. Signs of infection appeared on 6/6/17 (six days later) as an elevated white blood cell count (wbc), which developed into a surgical site (right hip incision) infection which required intravenous (IV) antibiotic therapy with three different antibiotics, and transfer back to the acute care hospital (5M/N unit) on 6/13/17. Patient #1 had surgery on 6/15/17 for surgical irrigation and debridement of the infected right hip for a diagnosis of "Drainage from Wound", and contaminated deep and superficial layers". A Physician's Infectious Disease Consultation Report dated 6/19/17 documented that microbial cultures of the right hip surgical site was positive for infection with Staphylococcus aureus. The report noted, "Right hip acutely infected wound, with purulent drainage, tenderness and redness."

On 1/4/18 at approximately 1030 further review of patient #1's medical record revelaed a Discharge Summary dated 6/28/17 at 1111, which documented that Patient #1 was discharged to a skilled Nursing Facility (nursing home) with diagnoses which included infected prosthesis, and Cellulitis of Right Hip. A wbc Laboratory value dated 6/28/17 documented continued leukocytosis (elevated wbc), and the patient was discharged to a SNF on 6/28/17 with IV antibiotics and a wound vac.

On 1/4/18 at approximately 1520, review of licensing and training records for the Acute Care Rehab Unit Midnight shift Nursing supervisor on 5/30/17 (identified on 1/4/17 at 1500 through revivew of staff schedules) and the staff nurse identified on Patient #1's 5/30/17 Incident Report for "Inappropriate Treatment" revealed that neither one had received training on Negative Pressure Wound Therapy (wound vac).

On 1/5/18 at approximately 1400, The Chief Nursing Officer, Staff C and the Safety and Quality Director, Staff A were interviewed regarding Patient #1's "Inappropriate Treatment" Incident. When asked, Staff A and Staff B reported that they had not attempted to identify the Nursing Shift Supervisor who had advised Patient #1's staff nurse to remove the specialized wound vac dressing from Patient #1's fresh surgical wound and replace it with a wet to dry dressing in violation of facility policy.

The Chief Nursing Officer, Staff C was interviewed on 1/4/18 at approximately 1400 and stated that it was standard Nursing Practice and facility policy to call the surgeon for dressing change orders. Staff C stated that the Nursing Supervisor should have known this and advised the Staff Nurse accordingly. Staff C stated that facility policy for wound care stated that if a physician's order or wound care nurse order could not be obtained for a new dressing, a sterile dry gauze dressing should be placed over the wound until physician orders could be obtained. Staff C stated that Patient #1's surgeon, "always answers his phone 24/7 and would have wanted to be notified that the wound vac was out of order." Staff C reported that per facility policy, only "superusers", staff who had received additional training on negative pressure wound therapy, were allowed to change wound vac dressings.

On 1/4/18 at approximatly 1510, the facility Infection Control Preventionists were interviewed (Staff P, Staff Q and Staff R). Staff P stated that she was aware of Patient #1's Hospital Acquired Surgical Site Infection, and had conducted an investigation to try and identify causative factors. Staff P stated that she was not notified that Patient #1 had a wet to dry dressing placed on the surgical wound four days after hip replacement surgery. Staff P stated that was definitely a risk for surgical site infection and would have been a factor in her root cause analysis of the infection.

On 1/4/18 at 1600, review of the undated facility policy entitled, "Negative Pressure Wound Therapy, Clinical Practice Guideline and Procedures", revealed the following statements, "Maintain closed system. Alarm problem solving: Low battery, assure plugged in properly. Negative Pressure Wound Therapy (NPWT) Dressing change performed by superuser only. Obtain physician order to change dressing-contact primary surgeon first (even if not on call). If unable to reach primary physician, contact covering surgeon prior to initiating dressing changes to confirm the details of the dressing change. Report to physician or wound care nurse: inability to maintain seal, removal of NPWT dressing for inability to maintain seal."

On 1/4/18 at approximately 0830, wound care for Patient #3 was observed, performed by wound - ostomy care nurses Staff G and Staff H. After wound care was completed, and clean dressings applied to Patient #3's wounds, the bottle of wound cleanser solution fell on the floor of the patient's room. Staff G picked up the bottle of wound cleanser and, without cleaning or disinfecting it, placed it in a box with clean dressing supplies, and left the room. At approximately 0900, the Wound-Ostomy Care Manager, Staff F was asked whether it was acceptable practice to place a bottle of wound cleanser that had fallen on the floor back with clean dressing supplies without disinfecting it. Staff F stated, "No. I'll have someone throw that bottle away immediately."