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Based on observations, interviews, record reviews, and review of facility procedures, the registered nurse(s) failed to evaluate the care provided and to implement appropriate nursing measures to prevent falls for 1 of 10 patients ( Patient #5), and failed to ensure a sanitary environment with facility procedures followed in providing wound care 1 of 10 patients (Patient #4).

Findings:

Patient #5:

Admitted to the 4th floor Medical unit on 07/05/2015 after examination in the Emergency Room (ER) for perfuse diarrhea, slightly dehydrated, with his wife being very overwhelmed given his bowel incontinence. With a history of coronary artery disease with past stents, and is currently on chemotherapy and radiation for lung cancer.

During an interview on 07/30/2015 at 2:10 PM, with Register Nurse ( RN) #1, stated that he must of forgotten to turn the be alarm and recheck it after giving Patient #5 a medication earlier that evening. He further stated that after checking the bed alarm after patient #5's fall, he confirmed that the alarm was not on.

Record review of facility ' s policy titled, " Fall prevention " , showed that who is at risk for falls, to consider a patient over 80 years old, history of falls, and gait or balance impairment. Optional equipment includes use of bed alarm. Patient #5's Fall Risk score = 35, Fall Risk Class+ moderate risk

Medical record review revealed, that Register Nurse #2, documentation on 07/07/2015 revealed the nurse's comment: At 0115 AM, nurse outside the room heard a loud crash, and entered the room to find the patient on the floor between the bed and window. Assisted the patient to the Bedside Commode (BSC): patient confused but consistent with mentation prior to fall. No complaint of pain, no apparent injury.

Review of the incident report dated 07/07/2015 at 3:58 AM revealed that RN#2, outside the room heard a loud crash in the room. Entered the room to find the patient on the floor. Siderails up X 2, BED ALARM NOT ON, patient connected to monitor, Oxygen, and Foley catheter. Assisted patient to the Bedside Commode (BSC) X 2 assist. No apparent injury, patient in no acute distress, and reports no pain or discomfort. Assisted back to bed, bed alarm set, and physician notified.


Patient #4:

Admitted from a Skilled Nursing Facility (SNF) due to complaint of shortness of breath and some swelling to his right leg. He was diagnosed with Congestive Heart Failure (CHF), abnormal labs, Stage 4 chronic renal failure and was admitted to the 4th floor Medical unit on 07/021/2015 for CHF. Skin assessment revealed that he had Stage 2 pressure ulcer to his sacrum, with physician orders to cleanse with soap and water, dry thoroughly

An observation on 07/30/2015 at 11:40 AM with RN #1 (registered nurse) showed that the wound care for Patient #4 revealed the RN collected all needed supplies. The nurse introduced herself to patient #4, and stated the procedure to be performed. The RN washed her hands, applied gloves, and removed the old dressing. Then without changing gloves the wound care nurse sprayed Peri Wash cleanser on a washcloth, cleansed the patient's wound of his sacral pressure ulcer and excoriated wound, patted it dry with a dry washcloth, then cleansed the wound site with NS, (normal saline), and removed her gloves without washing her hands applied another pair of gloves. RN #1 then applied a foam dressing to the wound site and dated and initialed the dressing.

During an interview on 07/30/2015 at 12:25 PM with RN #1 revealed verification that she did not wash her hands after cleansing the wounds and applying the physician ordered dressing, and prior to applying a clean pair of gloves.


Record review of the facility's procedure titled " Surgical wound dressing application" showed that after the RN removed the dressing. To observe the dressing for the amount, type, color and odor of drainage and discard the dressing and your gloves in the appropriate receptacle. Next step is to perform hand hygiene.

During an interview on 07/30/2015 at 1:20 PM, with the Director of Infection Control, confirmed that the wound care nurse according to the facility's procedures for wound care it to wash hands between changing gloves.