HospitalInspections.org

Based on observation, interview and policy review, the facility failed to ensure patients were educated and offered privacy from video monitoring during personal care and toileting for three patients (#43, #44 and #45) of four patients reviewed for privacy. Approximately 250 of the facility's patient beds had video monitoring capability, on seven units. The facility census was 328.

Findings included:

1. Record review of the facility's policy titled, "Patient Monitoring," dated 04/2015, showed that the primary nurse was responsible for providing patient and family education regarding the monitoring system. The policy also gave direction for staff to activate the Nurse Privacy button when providing direct patient care. Activation of the privacy button will block the (patient monitored) image from viewing for 15 minutes. If the staff needs more than 15 minutes, they can press the privacy button another time.

2. Observation on 01/06/16 at 10:50 AM, showed Staff VVV, Registered Nurse (RN) uncovered Patient #43, to change a colostomy (a surgically created opening in the abdominal wall through which digested food passes) bag. During the patient's care, the patient's breast and abdomen were exposed. Staff VVV did not activate the patient's privacy button, and the care was observable on a monitor in the nurses' station.

Observation of the 5th floor nurses' station video monitor, and concurrent interview with Staff UUU, Nurse Manager, on 01/06/16 at approximately 11:20 AM, showed 24 patients were monitored by camera on the 5th floor Nephrology/Metabolic (kidney disorder/bodily chemical process) Unit. Staff UUU, Nurse Manager, stated that nurses were responsible for educating patients about the video monitoring and were expected to stop the video surveillance of patients when they provided patient care or during toileting and baths.

Observation on 01/07/16 at 9:07 AM, showed Staff YYY, RN, changed Patient #44's dressing, which was located around her tailbone. During the dressing change, the patient's perineal area (the genitals) was exposed. Staff YYY did not activate the patient's privacy button, and the care was observable on a monitor in the nurses' station.

Observation on 01/07/16 at approximately 10:00 AM, showed Patient #45 on the video monitor at the 3 North nurses' station. The patient was seen sitting on a commode in the patient's room.

During an interview on 01/07/16 at 10:20 AM, Patient #45 stated that she was not aware she was being monitored by video while on the commode, and when asked if it bothered her, stated that she liked her privacy.

During an interview on 01/07/16 at approximately 10:30 AM, Staff XXX, RN, stated that patients were able to "opt out" of video monitoring if they chose. Staff XXX stated that she placed Patient #45 on the commode and did not shut off the video monitoring, but was unable to give a reason why.

Based on observation, interview, record review and policy review, the facility:
- Failed to ensure nursing staff consistently and accurately assessed, supervised and evaluated nursing care for wounds and/or pressure sores/ulcers (injury to the skin and/or underlying tissue usually over a bony prominence) for three current patients (#8 and #34, and #44) of 11 current patients reviewed, and one discharged patient (#15) of one discharged patient reviewed.
- Failed to provide skin care consults per facility policy for three current patients (#8, #34 and #44) of 11 current patients reviewed, and one discharged patient (#15) of one discharged patient reviewed.
- Failed to follow wound care treatment orders for two current patients (#8 and #34) of 11 current patient wound/pressure sores reviewed.
- Failed to obtain wound care treatment orders for two current patients (#34 and #44) of 11 current patients and one discharged patient (#15) of one discharged patient wound/pressure sores reviewed.
- Failed to auscultate vascular access (listen, with the aid of a stethoscope, sounds in the blood vessel) to assure the vessel was not blocked before starting dialysis (the clinical purification of the blood by dialysis, as a substitute for the normal function of the kidney) for one patient (#41) of one patient observed during dialysis.
- Failed to label a Mediport (a small medical appliance that is installed beneath the skin in the chest region and connects the port to a vein, and is used administer medications and draw blood) access dressing for one patient (#5) of one patient observed with a Mediport dressing.
- Failed to label intravenous (IV, in the vein) catheter (flexible tubing used to withdraw or administer fluids or medication) sites and/or tubing for nine patients (#1, #3, #20, #21, #22, #23, #27, #30, and #34) of 19 patients' IV's observed.
These failures had the potential to cause harm to all patients with skin care issues, and had the potential to lead to IV site or bloodstream infections, if IV sites or tubing were not changed according to facility policy. The facility census was 328.

Findings included:

1. Record review of the facility's policy titled, "Pressure Ulcers: Management and Treatment of the Patient at risk for and with existing Pressure Ulcers," revised on 03/2014, showed the following:
- All patients will be assessed utilizing a pressure ulcer risk screening tool called the Braden Scale, on admission and every shift thereafter. Lower scores indicate greater risk (10-12 High, 13-14 Moderate, 15-18 Mild).
- Any patient with a Braden (score) of 13 or less will require a skin care clinician consult.
- The nurse will document location, type, drainage (amount, color, odor), size and color of wound bed.
- The nurse will obtain treatment orders for pressure ulcers.
- The nurse will measure and document those measurements on admission, upon initial identification, on each Wednesday, or with dressing changes.
- Multiple wounds are numbered to correspond with the wound number (a diagram of an anatomical man) in the computer system.

2. Record review of current Patient #34's History and Physical (H&P) dated 01/06/16, showed the patient was admitted on 01/05/16 with poor circulation and multiple ulcers on his right lower leg. The patient had a history of diabetes (can contribute to poor circulation) and a left above-knee amputation related to poor circulation.

Record review of a podiatry consult (foot care doctor) dated 01/05/16, showed the patient had the following:
- An area of eschar (dead tissue) on the right big toe measuring 1.0 centimeters (cm-a unit of measure) by 1.5 cm.
- An area of discoloration on the right second toe.
- A full thickness ulceration on the posterior (back) calf measuring 3.0 cm by 4.0 cm, with a small amount of eschar.
- A blistered lesion on the front of the calf measuring 7.0 cm by 7.0 cm.

Record review of a podiatry consult dated 01/06/16, showed the following:
- The right big toe eschar measured 2.0 cm by 2.0 cm.
- The right second toe discoloration measured 1.0 cm by 2.0 cm, with eschar.
- The anterior and posterior calf ulceration measurements remained the same.
- The type/cause of the ulcers showed "Pressure, Arterial, Stage II" (partial thickness skin loss, usually presenting as an abrasion, blister, or shallow crater.)

Record review of an Adult Admission Systems Assessment dated 01/05/16 at 5:27 PM, showed the following:
- A Braden score of "16;"
- Several blistered areas to the left lower leg (should be right leg), labeled as "Blister, Wound #1.
- No other wounds were identified, documented, and/or measured per the facility policy on admission.

Record review of an Adult Shift Assessment dated 01/05/16 at 9:35 PM, showed the following:
- A yellow sore on the upper right leg measuring 1.0 cm by 1.0 cm, labeled as "Skin tear, Wound #1 (even though Wound #1 was on the lower leg on the previous assessment).
- Several blisters to the right lower leg, labeled as "Blister, Wound #2.
- Foot ulcers on the right big two toes, 100% black, measuring 1.0 cm by 1.0 cm, labeled as foot ulcer, Wound #3 (even though this involved two toes, there was only one measurement and description).
- An open area on the right upper knee with a yellow sore. Staff failed to measure and label this area.

Record review of an Adult Shift Assessment dated 01/06/16 at 8:00 AM, showed the Braden score was lowered to "12," the dressing was changed on the right lower leg, the toes were blackened and there was a yellow sore on the right upper knee. The assessment showed no further description and/or measurement of these wounds.

Even though requested, the facility could not provide evidence of a skin care consult for this patient.

Record review of physician's orders dated 01/05/16, showed staff were to treat the front of the right lower leg with a Vaseline gauze, ABD (thick gauze pad) and Mepilex (an absorbent, but padded dressing). Staff were to treat the back of the right lower leg with Vaseline gauze and Mepilex, both sites twice daily. Even though requested, the facility failed to provide an order for treatment to the right knee.

3. Observation on 01/06/16 at 10:17 AM, on the 3rd floor, showed current Patient #34 had the following:
- A large area (approximately 20 cm) of darkened, taut, weeping skin, on the right lower calf, from the ankle to about two inches from the knee, completely surrounding the calf. There was a large blister, partially filled, on the front, outer calf region, and some small open areas throughout.
- A black circular area of eschar on the tip of the right big toe measuring approximately 2.0 cm by 2.0 cm.
- An elongated, oval shaped black area on tip of the right second toe measuring approximately 1.0 cm by 1.5 cm.
- A blackened circular area on the right knee measuring approximately 1.0 cm by 0.8 cm.
- Staff PP, Registered Nurse (RN), placed ABD pads on the entire circumference of the patient's calf wounds, front and back, contrary to the orders.
- Staff PP also placed a small dressing on the right knee.

4. Record review of an Adult Shift Assessment dated 01/06/16 at 10:49 PM, showed the same wounds as labeled on the 01/05/16 9:35 PM assessment. The two toes were still not separately described and/or measured, as well as not for the right knee.

5. Record review of current Patient #8's H&P dated 12/30/15, showed the patient was admitted to the geriatric psychiatric unit on 12/29/15 with a diagnosis of major depressive disorder (a long period of feeling worried or empty with a loss of interest in activities once enjoyed). The patient had a history of bowel and bladder incontinence (lack of control), persistent diarrhea, and was wheelchair bound (all can contribute to skin breakdown), and some Stage II pressure sores on her buttock (no sizing information provided). The physician recommended a wound care consult.

Record review of the patient's Braden scores showed "13," from admission through 01/02/16, which would require a skin care consult per policy.

Even though requested on 01/05/16, the facility failed to provide evidence of a skin care consult.

Record review of the admission Nurse Assessment dated 12/29/15, showed the patient had pressure sores on the left buttock as Wound #1, and a pressure sore on the right buttock as Wound #2. Staff failed to stage, describe, or measure the pressure sores.

Record review of wound/incision care orders dated 12/29/15, showed staff were treat the patients skin breakdown with Triamcinolone cream (an anti-inflammatory cream) topically, twice daily.

Record review of wound/incision care orders dated 12/30/15, showed staff were to treat the patient's skin breakdown with skin barrier cream twice daily.

Record review of skin treatment records from 12/29/15 through 01/06/16 showed staff failed to document treatment 14 of 17 times.

During an interview on 01/06/16 at 9:57 AM, Staff III, Assistant Chief Nursing Officer and Vice President of Operations for the Behavioral Health Units, stated that she expected staff to document treatments as performed per the physician's orders. Staff III confirmed there was no documentation of measurements.

6. Observation on 01/04/16 at 2:17 PM, on the geriatric psychiatric unit, showed Patient #8 had an elongated Stage II pressure sore on the left upper hip that measured approximately 0.25 cm by 0.50 cm. There was a large area of excoriation (reddened, rash type area) surrounding the pressure sore.

Even though requested, the facility failed to provide evidence of staging, description or measurement of this pressure sore.

7. Record review of current Patient #44's H&P dated 01/05/16, showed the patient was admitted on 01/05/16 with a decubitus ulcer (wound) on her sacrum (tailbone) and one on her lower left buttock. The patient had a history of cerebral palsy (disorder of movement, muscle tone, or posture), was wheel chair bound, and with multiple decubitus ulcers (pressure ulcers). The plan (not written as a physician's order) for the patient included wound care with wet-to-dry dressings twice daily.

Record review of an adult admission assessment dated 01/05/16 at 8:30 PM, showed:
- A Braden Score of 13;
- Wound 1, A Stage II pressure ulcer to the left buttock which measured 3 cm long by 3 cm wide, by 0.2 cm deep;
- The wound was cleansed with saline (salt water solution) and a wet to dry dressing was placed on the wound, and;
- No other wounds were identified, documented, and/or measured per the facility policy on admission.

Record review of a shift assessment dated 01/06/16 at 8:00 AM, showed:
- A Braden Score of 13;
- Wound 1 measured 4 cm long by 3 cm wide, by 1 cm deep;
- The wound was cleansed with a wound cleanser and a Hydrocolloid dressing (a clear dressing which contains gelatin and other ingredients used to heal wounds) was applied, and;
- No other wounds were identified, documented, and/or measured per the facility policy on assessment.

Record review of a shift assessment dated 01/06/16 at 8:25 PM, showed:
- A Braden Score of 13;
- Wound 1 was not measured;
- The wound was cleansed with a wound cleanser, and a wet to dry dressing was applied, and;
- No other wounds were identified, documented, and/or measured per the facility policy on assessment.

Even though requested, the facility could not provide evidence of a skin care consult, or a physician's wound care order for the Stage II pressure ulcer for this patient.

8. Record review of discharged Patient #15's H&P dated 10/31/15, showed that the patient was admitted on 10/31/15 with:
- A gangrenous (death of tissue cause by inadequate blood supply) second digit (toe) on the right foot;
- Multiple left foot wound ulcers, which were draining, with concerns for osteomyelitis (infection in the phone);
- Cellulitis (infection on the skin) of the left leg;
- Blister on the back and outside of the left leg;
- A left foot wound, Stage IV (with bone showing);
- A Stage I (reddened area on the skin which is not open) wound to the top of the left foot;
- Stage II ulcers to both the left and right buttock, which were healing;
- No other wounds; and
- A history of a partial amputation of the left metatarsal (foot).

Record review of an adult admission assessment dated 10/31/15, showed only three wounds documented:
- Wound 1 location - right buttock;
- Wound 2 location - left buttock; and
- Wound 3 location - left foot.
There was no length, width or depth of the wounds documented, no description of the wounds documented, no description of the drainage documented or dressings documented. The patient's Braden score was 12.

Record review of nurse "Wound 1" assessment documentation showed:
- The wound was located on the right buttock from 10/31/15 through 11/11/15;
- The wound was located on the coccyx (tailbone) from 11/12/15 through 11/17/15;
- The wound length was documented as 12 cm on 11/12/15, 4 cm on 11/13/15 and 12 cm on 11/14/15;
- The wound width was documented as 12 cm on 11/12/15, 4 cm on 11/13/15 and 12 cm on 11/14/15; and
- The wound was documented as intact (together, healed or closed) from 11/04/15 through 11/13/15.

Record review of nurse "Wound 2" documentation showed:
- The wound was located on the left buttock from 10/31/15 through 11/12/15;
- The wound was located on bilateral buttocks on 11/13/15;
- The wound was located on right back from 11/14/15 through 11/17/15;
- The wound measured 2 cm long by 2 cm wide on 10/31/15; and
- The wound was not measured during the remainder of the patient's stay.

Record review of nurse documented "Wound 3" showed:
- The wound was located on the left foot from 10/31/15 through 11/05/15;
- The wound was located on the left lower leg from 11/06/15 through 11/11/15;
- The wound was located on the right buttock on 11/12/15; and
- The wound was located on the left buttock from 11/13/15 through 11/17/15.

Record review of physician orders, showed there was no wound care orders by a physician until 11/12/15, 13 days after the patient was admitted.

Record review of Braden score documentation showed that the patient scored between 7 and 16 during her stay from 10/31/15 through 11/17/15.

Even though requested, the facility could not provide evidence of a skin care consult for this patient.

9. Observation with concurrent interview on 01/07/16 at 9:07 AM, showed Staff YYY, RN, provide wound care to Patient #44. The patient had a foam dressing on her coccyx and on the patient's left lower buttock. The coccyx wound was healed except for sloughing skin, and the left buttock wound measured approximately 8 cm long by 3 cm wide, with no depth. The measurement was verified by a second surveyor. The nurse reported that the wound measured 2.8 cm long by 1 cm wide, with no depth.

During an interview on 01/06/16 at 2:12 PM, Staff QQQ, RN and Director of Clinical Excellence, and Staff RRR, RN, and Intensive Care Unit Educator, stated the following:
- The facility's skin care consultant retired in 2014 and they had not re-filled the position.
- Because there was no skin care consultant, when physician's requested a skin care consult, it did not happen.
- Any stageable wound should have a specific wound care order written by a physician.
- Wounds (all) should be assessed on admission, to include site, stage, description, and measure. Wounds should be assigned a number and that number should remain with that specific wound throughout the hospitalization.
- Wounds should be re-measured with each dressing change.
- All orders for treatment were to be followed and documented.
-Their current wound care policy did not reflect the current process expectations for wound.

10. Record review of the facility's policy titled, "Assessment and Preparation of Internal Access for Needle Placement" for Dialysis, dated 01/28/15, showed directives for staff to auscultate vascular access by listening to the entire length of the access for changes in the sound of the bruit (noise of the blood flow). A low pitched bruit should be present and if no sound is present, assume the access is thrombosed (blocked), do not attempt cannulation (needle with tube insertion), and contact the attending physician.

11. Observation on 01/06/16 at 9:40 AM in the inpatient Dialysis Treatment Area showed Staff KKK, Certified Clinical Hemodialysis Technician (CCHT), in the room with Patient #41 to administer a dialysis treatment. Staff KKK inserted a needle into the patient's blood vessel and connected the dialysis tubing (filled with the patient's blood) to the dialysis machine without auscultating (listening with the aid of a stethoscope) to the patient's blood vessel.

During an interview on 01/06/16 at 11:00 AM, Staff KKK, CCHT, stated that she did not auscultate the patient's blood vessel and she did not know if the RN auscultated the patient's blood vessel prior to the needle insertion and administrating dialysis.

During an interview on 01/06/16 at 11:05 AM, Staff JJJ, RN, stated auscultated the patient's blood vessel after the needle insertion and not before the insertion. She stated that she did not know until questioned, that Staff KKK had not performed auscultation and she should have done so.

During an interview and concurrent policy review on 01/06/16, Staff LLL, Dialysis Patient Services Manager, stated that the nurse usually auscultates the patient's blood vessel before needle insertion; and currently there was no process to assure that either a nurse or CCHT auscultated the patient's blood vessel before inserting the needle and initiating dialysis.

12. Record review of the facility's policy titled, "Intravenous Access Management Policy," dated 02/2015, showed that IV sites are labeled with the date and time of insertion or date and time of last dressing change, and IV tubing is labeled with the date and time to be changed.

13. Observation on 01/04/16 at 2:15 PM showed Patient #5 with an unlabeled Mediport dressing.

During an interview and concurrent review of Patient #5's record on 01/04/16 at 2:55 PM, Staff DD, RN Unit Director, stated that according to policy, the dressing should have been labeled when the port was accessed in the emergency department.

14. Observations from 01/04/16 to 01/06/16 showed patients (#1, #3, #20, #21, #22, #23, #30) with medication infusing through unlabeled IV tubing and patients (#27 and #34) with an undated IV catheter dressings.

During an interview on 01/06/16 at 1:30 PM, Staff KK, Chief Nursing Officer (CNO), stated that staff were expected follow policies and procedures and label all dressings and Dialysis staff were expected to follow Dialysis policies and procedures.




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