HospitalInspections.org

Based on review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure oral care was provided to the patient on a ventilator for one of one medical record reviewed (MR1).

Findings include:

Review on August 26, 2014, of the patient's "Patient Rights and Responsibilities" policy, last reviewed/revised July 2013, revealed "We consider you a partner in your hospital care. When you are well informed, participate n treatment decisions, and communicate openly with your doctor and other health professionals, you help make your care as effective as possible. At Robert Packer Hospital, we encourage respect for the personal preference and values of each individual. ... 3. You have the right to good quality care and high professional standards that are continually maintained and reviewed ... ."

Review on August 26, 2014 of the facility's "ICU Ventilator Bundle VAP Prevention" policy, revised September 2013, revealed "... - Oral Care Q2 [every 2] hours per protocol - brush teeth BID [twice a day] - chlorhexidine solution BID ... ."

Review on August 26, 2014, of the facility's "Ensuring Patient Safety The Role of Good Mouth Care" power point presentation, no review date, revealed "... Initial Assessment ... need to be able to fully visualize the mouth to assess for problems Assess oral cavity for inflammation, bleeding, areas of breakdown, pressure points, candidiasis, secretions, and salivary flow (dryness) ... ."

Interview with EMP3 on August 26, 2014, at approximately 11:00 AM revealed the "Ensuring Patient Safety The Role of Good Mouth Care" power point presentation is presented to new nursing staff during orientation. The power point presentation is not provided at other times during employment.

Review of MR1 on August 25, 2014, revealed the patient was admitted to the facility on June 20, 2014, and was intubated (breathing tube inserted through the mouth to the lung to assist with breathing) on June 22, 2014. Documentation revealed the patient was restrained with soft wrist restraints and sedated. The breathing tube was removed on June 24, 2014. Further review revealed 75 - 100 maggots were coming from the patient's mouth and nose following the removal of the breathing tube.

Review of MR1 on August 25, 2014, revealed nursing documentation that mouth care was performed every two hours while the patient was intubated. Further review revealed no documentation nursing staff brushed MR1's teeth, used chlorhexidine solution twice a day or assessed MR1's mouth for problems while the patient was intubated, as required by facility policy.

Interview with EMP3 and EMP5 on August 25, 2014, at approximately 12:45PM confirmed nursing staff performed MR1's of mouth care every 2 hours while intubated; and there was no documentation nursing staff brushed MR1's teeth or assessed the patient's mouth for problems while intubated. Further interview with EMP3 confirmed 75 - 100 maggots were coming from this patient's mouth and nose following the removal of the breathing tube. EMP3 and EMP5 confirmed nursing staff was responsible for mouth care. EMP3 and EMP5 confirmed the nursing staff follow the standard of practice for mouth care using lemon glycerin swabsticks or the toothette oral care single use system with perox-a mint solution and mouth moisturizer. EMP3 and EMP5 confirmed there was no written policy or procedure instructing nursing staff how to perform mouth care.

Interview with EMP2 on August 25, 2014, at approximately 2:30PM confirmed nursing staff follow the standard of practice for mouth care, and the facility does not have a written policy or procedure instructing nursing staff how to perform mouth care.

Interview with EMP8 on August 25, 2014, at approximately 2:45 PM confirmed the time frame when a fly lays an egg to the maggot stage is 24 hours.

Interview with EMP3 on August 26, 2014, at approximately 11:35AM confirmed there was no documentation nursing brushed MR1's teeth or used chlorhexidine solution twice a day. EMP3 confirmed the care partner completes the mouth care, and the registered nurse is responsible for ensuring the mouth care is completed, and the patient's mouth is assessed for problems.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure the bug lights in the Intensive Care Unit (ICU) were maintained in working order.

Findings include:

Review on August 25, 2014, of the facility's "Pest Control Service" policy, last reviewed on April 4, 2014, revealed "Policy: Pest control services at RPH [Robert Packer Hospital] will be handled according to the following procedure: Specifics: 1. [Name of vendor] Pest Control is the contacted vender. 2. A service technician visits the hospital once a week to assess problems and treat areas that have need. 3. Any area that has a problem with pest control is to call the EVS [environmental services] Department. 4. All calls are documented in a log book which [Name of vendor] checks on arrival. 5. [Name of vendor] is available to come on other days as emergency need arise."

Observation on August 25, 2014, at approximately 11:30 AM revealed two bug lights in the second floor ICU. Further observation revealed the bug lights were on and working.

Interview with EMP3 on August 26, 2014, at approximately 10:30 AM revealed after the maggots were identified in MR1's mouth and nose, a work order was placed on June 24, 2014, instructing the maintenance department to install bug lights in the second floor ICU. EMP3 confirmed a bug light was installed in the second floor ICU last year (2013). EMP3 confirmed the bug light from 2013 was not working when maintenance installed the two new bug lights on June 26, 2014.

Interview with EMP10 on August 26, 2014, at approximately 9:50 AM confirmed there was no written policy or procedure for the installation and maintenance of facility bug lights.

Cross reference:
482.13(a) Patients Rights: Notice of Rights