HospitalInspections.org

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Based on observations and staff interview, the facility failed to ensure the patients' right to privacy including the patients' presence and location in the facility. This was evident in the Telemetry Unit.

Findings:

During a tour of the Telemetry Unit on 10/16/14 at 10:40AM four (4) separate Telemetry Monitors were observed hanging on the walls of the two (2) main hallways with a total of forty-three (43) patients' full names (last and first names) in view of anyone on the Unit.

This observation was made in the presence of Staff Members #4 and #8.

Interview with Staff #1 revealed "The names were discussed with the Team and it had been determined that it was okay because of the type of Unit it is".
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Based on record review and staff interview, the facility failed to ensure that the Nursing Staff: a) appropriately assessed patients when transferred from one Unit to another, and b) developed patient specific Nursing Care Plans. This was evident in four (4) of seven (7) Medical Records reviewed (Patients #17, #21, #26 and #34).

Findings:

a) Review of Patient #17's Medical Record revealed that the patient was brought to the Emergency Department (ED) on 10/12/14 for shortness of breath. The patient's skin was assessed in the Emergency Department as having a Stage 3 Pressure Ulcer on the Sacrum.

The patient was then admitted on 10/12/14 to the 3W Unit with a diagnosis of Pneumonia. The patient's skin was reassessed upon admission to the Unit and was classified as having a Stage 2 Pressure Ulcer on the Sacrum.

Interview with Staff #6 revealed "I did not see him".

Review of Patient #21's Medical Record revealed that the patient was brought to the ED on 10/14/14 for chest pain. The patient's skin was assessed in the ED as having a Stage 1 Pressure Ulcer on the Sacrum.

The ED Physician documentation notes "Sacrum unstageable decubiti".

However, when the patient was admitted on 10/14/14 to the Telemetry Unit, the patient's skin was reassessed and was classified as having a Stage 2 Pressure Ulcer on the Sacrum.

This discrepancy was confirmed and acknowledged upon interview with Staff #3 in the presence of Staff #4.

Similar findings were found on review of the Medical Record for Patient #4.

Review of Patient #26's Medical Record revealed that the patient was brought to the ED on 10/13/14 for shortness of breath. The patient's skin was assessed in the ED as having a Stage 1 Pressure Ulcer on the Sacrum.

The patient was then admitted on 10/13/14 to the Telemetry Unit with a diagnosis of Congestive Heart Failure. The patient's skin was reassessed on the Unit and was classified as having no Pressure Ulcers on the Sacrum. No other documentation noted any skin concerns upon admission.

The patient's skin was reassessed on 10/14/14 with no concerns noted. Documentation in the Medical Record notes two (2) days after admission, on 10/15/14, that the patient had a Left Necrotic Toe. Staff failed to identify and document the condition of the toe in the ED and on the Admission Assessment to the Unit.

This was confirmed and acknowledged upon interview with Staff #3 in the presence of Staff #4.

b) Review of Patient #18's Medical Record on 10/15/14 revealed that the patient was admitted on 10/10/14 with Bacterial Enteritis and C-Difficile. The patient also had a Pressure Ulcer on the Sacrum.

Review of the patient's generic automatically populated Care Plan failed to indicate that the patient was on Contact Precautions and did not address the Pressure Ulcer. The patient's Care Plan was not patient specific.

Review of Patient #26's Medical Record on 10/15/14 revealed that the patient was admitted on 10/13/14 and was determined to have a Stage 1 Pressure Ulcer on Bilateral Heels and a Left Necrotic Toe.

The patient's generic automatically populated Care Plan failed to indicate that the patient had the Necrotic Toe and did not address the Pressure Ulcer. The patient's Care Plan was not patient specific.

Interview with Staff #3 revealed the "Clinical Practice Guidelines (CPG)" are to be initiated within twenty-four (24) hours of admission.

Review of the Policy titled "Knowledge Based Charting Documentation" Section III, #3 confirmed the same, and also states "...CPG will be individualized...".
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Based on observation, record review and interview the facility failed to ensure that: a) the Nursing Staff followed acceptable standards of practice for administration of medications via Gastronomy Tube (G-Tube) to decrease the risk for aspiration in two (2) of two (2) observations (Patients #17 and #24), and b) the wall unit where patient medications are kept was locked and secure.

Findings:

a) Patient #24 was admitted on 10/14/14 for a chief complaint of abdominal pain and had a Gastrostomy Tube in place upon admission.

On 10/16/14 at 11:45AM, prior to administering medication to Patient #24 via G-Tube, Staff #9 was observed to attach the syringe to the Gastrostomy Tube and then apply the plunger, making it impossible to pull back to check for residual.

Staff # 9 stated that she is responsible for checking the residual before administering the medication via the G-Tube.

Review of the Nursing Policies and Procedures revealed that the facility lacked a Policy for administering medication via G-Tube; i.e. ordering an amount of residual to assess risk for aspiration, how frequently to assess, the amount of residual that would be acceptable, and the recommended position of the patient during medication administration.

On 10/17/14 at 2:00PM Staff #10 was asked if there was a Policy and Procedure for administering medication via Gastrostomy Tube. Staff #10 replied that there was no specific Policy for administering the medication via the G-Tube and that they use the Lippincott Standard of Care Protocol. This Protocol does include assessing for residual before administering medication.

Staff #10 also stated that checking residual was in question in the Medical Community and that the facility was rethinking their process.



33919

Patient #17 was admitted on 10/12/14 with a diagnosis of Pneumonia. The patient also had a diagnosis of Mental Retardation and a Percutaneous Endoscopic Gastrostomy (PEG) Tube for feedings.

On 10/15/14 at 11:25AM Staff #7 was observed administering medication to Patient #17 via his PEG Tube. The patient was receiving a continuous feeding at the time of the medication administration, and the Nurse failed to check for residual prior to administering the medication.

This was observed in the presence of Staff Members #1 and #2.

On 10/15/14 at 11:25AM Staff #7 was observed administering medication to Patient #17 via his PEG Tube. The patient was receiving a continuous feeding at the time of the medication administration and the Nurse failed to check for placement prior to administering the medication.

This was observed in the presence of Staff Members #1 and #2.

Review of the Policy titled "Medication Administration" revealed that the Policy does not address or give instructions for the administration of medications through feedings tubes.

This was confirmed and acknowledged by Staff #1.

b) On 10/15/14 at 11:20AM Staff #7 was observed leaving the wall unit in the hallway, where patient medications are kept, open and unattended while she was in a patient's room. Medications were unlocked and easily accessible to anyone in the hallway on the Unit, including other patients and visitors.

This was observed in the presence of Staff Members #3 and #2.

During an interview with Staff #7 the staff member stated "I have to crush meds, that's why I left it open".

On 10/15/14 at 12:00PM the same wall unit was observed open and unattended.

This was observed in the presence of Staff #2.
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Based on observation, documentation and interview, the facility failed to ensure that Infection Control Practices were maintained: a) for a patient on Isolation, b) during medication administration via feeding tube, c) for cleaning supplies on the cart in an Isolation Room, and d) for storage of patient equipment. This is evident in two (2) of two (2) observations (Patients #17 and #18).

Findings:

a) Patient #18 was admitted on 10/10/14 with a diagnosis of Bacterial Enteritis and C-Difficile. The patient was placed in Isolation on Contact Precautions.

On 10/15/14 at 11:50AM, Staff #5 was observed administering Intravenous (IV) antibiotics to Patient #18.

During the observation, it was noted that there were several IV medication bags on the Nurse's cart in the Isolation Room. Upon further investigation, it was noted that the medication bags were for several other patients.

This was confirmed and acknowledged in the presence of Staff Members #2 and #4.

b) On 10/15/14 at 11:30AM Staff #7 was observed administering medications via feeding tube to Patient #17.

Staff #7 was observed donning gloves without performing hand hygiene prior to medication administration.

This observation was made in the presence of Staff #2.

The facility lacks a Policy for medication administration via feeding tubes and therefore does not address hand hygiene.

c) On 10/15/14 at 11:50AM Staff #5 was observed with her cart in the Isolation Room of Patient #18.

During the observation, it was noted that the Sani-Wipes container on the cart was missing the lid and therefore the integrity of the wipes could not be guaranteed.

This observation was made in the presence of Staff #2.

d) On 10/15/14 at 11:15AM it was observed that unopened Sani-Wipes containers were being stored in cabinets in the Soiled Utility Rooms on the 3W Unit.

On 10/16/14 at 10:30AM it was observed that unopened Sani-Wipes containers were being stored in cabinets in the Soiled Utility Rooms on the Telemetry Unit.

These finding were confirmed and acknowledged with Staff #4.

On 10/16/14 at 10:40AM it was observed that a commode was being stored in the patient hallway shower.

When asked if the commode was clean or dirty, Staff #8 replied "I really don't know".

Review of the Policy titled "Cleaning and Disinfection" revealed in Section G, #3 that "Equipment cleaned and disinfected on a Patient Care Unit will be identified as clean and stored in the Clean Utility Room".