HospitalInspections.org

Surveyor: 32355


20031




26180

A. Based on observation, record review, interview, and policy review, the provider failed to ensure two of three dressing changes for one of two sampled patients (4) were completed using appropriate hand hygiene. Findings include:

1. Observation and interview of patient 4 on 6/18/19 at 9:00 a.m. with the physical therapist (PT) B revealed:
*The patient had severe lymphedema in her lower extremities.
*She had received a sore on the back of her left leg when she was trying to lift her legs into bed, and her leg caught on a medal plate on the frame of her bed.
*Since then she had vast amounts of serous drainage from that sore on her leg.
*Initially they covered it with ABD pads, but due to the amount of drainage it could not be contained in the pads.
*They had started using a disposable brief which was wrapped around her leg to absorb the drainage.
*While there continued to be a large amount of serous fluids in her body her leg was not as large as it had been, and the brief was not fitting as snugly as it had at first.
*When PT B was going to walk the patient, she complained the brief on her leg was saturated and felt like a diaper that was full and needed to be changed.
*With gloved hands the PT B removed the brief and disposed of it in the nearby garbage can.
*Without changing her gloves, the PT continued to:
-Put on another disposable brief.
-Assisted the patient to standup with the assistance of another unidentified PT.
-Ambulated the length of the hall and returned to her room.
-Assisted the patient to sit down.
-Continued to coach the patient in doing additional leg exercises.
*She did not remove her gloves until she was done with the patient.

Surveyor 32355
Observation on 6/19/19 at 8:30 a.m. with PT B during a dressing change for patient 4 revealed:
*The patient:
-Was obese and had been sitting in a chair in her room.
-Had lymphedema wraps on both of her legs and an incontinent brief wrapped around her left knee.
--The incontinent brief had been soaked with serous drainage from an opened wound on the back of her left leg.
*The PT entered the patient's room, sanitized her hands, and put on a clean pair of gloves.
*With those gloves on the PT removed the soiled incontinent brief from the patient's left knee and put a clean one on.
*The PT changed her gloves without sanitizing or washing her hands.
*With those gloves on she:
-Placed a wheeled walker (w/w) in front of the patient.
-Put a gait belt around the patient's waist and assisted her to stand-up.
-Adjusted the patient's gown and assisted the patient with walking down to the therapy gym by holding onto the gait belt.
-Assisted the patient to sit down on a therapy mat.
-Took a garbage can, placed it on its side, and covered it with a disposable chux.
-Opened two large garbage bags and placed them on the floor by the patient.
*The PT changed her gloves without sanitizing or washing her hands.
*With those gloves on she had:
-Adjusted the chair she was sitting on by moving a lever attached to the seat.
-Reached inside of her pants pocket, took out a pair of glasses, and put them on her face.
-Removed the patient's non-skid socks.
--The socks had been cut to fit on the patient's swollen feet and secured in place with several pieces of tape.
-Removed several pieces of tape from the non-skid socks.
-Removed the lymphedema dressing from her left leg.
*The PT removed her gloves and without sanitizing or washing her hands completed several measurements of the patient's swollen leg.
*The PT put on a clean pair of gloves without sanitizing or washing her hands.
*With those gloves on she:
-Opened a package of 4x4 gauze dressings.
-Sprayed the gauze dressings with wound cleanser and cleaned the left leg.
-Applied lotion to her left leg and foot.
-Re-dressed her left leg with several layers of lymphedema wrap.
*The PT changed her gloves and without sanitizing or washing her hands prepared to change the dressings on the patient's right leg.

Interview on 6/19/19 at 11:37 a.m. with the PT B revealed:
*The above observation had been her usual process for completing a lymphedema dressing change.
*She had not recognized the following surfaces as unsanitary:
-The soiled incontinent brief.
-Wheeled walker.
-Gait belt.
-Patient gown.
-The surfaces of the garbage can and garbage bags.
-The lever on the seat.
-Her pants pocket and glasses.
-The non-skid sock and tape.
-The old dressings from the lymphedema wrap.
-The outside of the 4x4 gauze package.
*She was not sure the dressing change above had been completed in an unsanitary manner.
*She stated:
-"I never sanitize or wash my hands when I change gloves."
-"I try to keep it as clean as possible as it's a clean process."
-"It's a clean technique not sterile."
*In the past she had been observed completing those types of dressing changes.
*She stated "No one ever said anything to me or that I didn't do it right during my lymphedema training."

Interview on 6/19/19 at 1:42 p.m. with the director of nursing regarding the above observation revealed she:
*Agreed:
-The wound care and dressing change for patient 4 had not been completed in a sanitary manner.
-That process had created the potential of cross-contamination of germs to have been transmitted to the patient.
*Had not observed the PT during dressing changes.

Review of the APIC of Infection Control and Epidemiology, 3rd Ed., Volume 1 Essential Elements, 2009, pp. 19-3, revealed:
*Page 19-3: "Use an alcohol-based hand rub unless hands are visibly soiled:
-Before and after direct patient contact.
-After contact with patient's skin.
-After removing gloves.
-After contact with objects and equipment in the patient's immediate vicinity."

Review of the provider's June 2019 Infection Control policy revealed:
*Purpose: "To prevent or control the spread of infection within [facility name]."
*Handwashing:
-"After handling soiled materials."
-"After handling all bodily secretions."
*Gloves: "Wearing gloves and changing them between patient contacts DOES NOT replace the need for hand-washing."

Review of the provider's 7/25/12 Wound Dressing Change policy revealed hands were to have been washed after the removal of soiled gloves and prior to putting on a clean pair.

Surveyor: 20031
B. Based on random observation, testing, and interview, the provider failed to maintain walls and ceilings in a durable, cleanable condition in five of five areas:
*Housekeeping closet.
*Bathroom in physical therapy (PT) gym.
*Emergency room (ER) supply room.
*Labor room.
*Two bed emergency room.
Findings include:

1. Random observation on 6/17/19 from 2:00 p.m. to 5:30 p.m. and again on 6/18/19 from 8:40 a.m. to 11:00 a.m. revealed:
*The housekeeping closet wall behind the mop sink was completely deteriorated. The wall had missing chunks of plaster that ranged in size from tennis balls to footballs. Those holes exposed the two by four studs behind the plaster.
*The bathroom wall by the sink in the PT gym had flaking and deteriorating plaster. Testing with a touch of a finger that plaster would fall from the wall. The area was about the size of a football.
*The ER supply room had:
-A deteriorated wall by the hopper in the alcove. The wall had chunks of plaster missing the size of quarters and dimes. The wall was bubbled and would crumble with the touch of a finger.
-The ceiling in the main supply area had flaking and peeling paint and plaster the size of a basketball.
*The labor room had unsealed peg board attached to the wall. That peg board held clean supplies to be used in emergency labor.
*The two bed ER had unsealed peg board attached to the wall.

Interview on 6/19/19 from 1:15 p.m. to 2:00 p.m. with the director of nursing confirmed all the above findings. She stated she was unaware:
*Of the condition of the plaster in the facility.
*The unsealed peg board must be sealed to be cleanable.
*Of any policy that dealt directly with the condition of the floors, walls, and ceilings.

C. Based on random observation, and interview, the provider failed to maintain the cleanliness and sanitary condition for all paper towel dispensers throughout the hospital and patient care areas. Findings include:

1. Random observation on 6/17/19 from 2:00 p.m. to 5:30 p.m. and again on 6/18/19 from 8:40 a.m. to 11:00 a.m. revealed all the paper towel dispensers had layers of grime and dirt on and under the push lever action handle. The heavily soiled light gray handles appeared brown to black in color.

Interview on 6/18/19 at 10:00 a.m. with the housekeeper confirmed the above findings. She stated she was not aware those paper towel dispensers and handles needed a deep cleaning. She revealed she would dust the dispensers but did not clean them.

Interview on 6/19/19 at 1:15 p.m. with the director of nursing revealed she had been made aware of the uncleanliness of the paper towel dispensers throughout the hospital. She stated she was unaware of any particular policy that dealt with the cleanliness of handwashing stations.

Based on record review, interview, and policy review, the provider failed to ensure the medical records were accessible and complete to support:
*Five of five sampled patients (19, 21, 22, 23, and 24) who had been admitted into the emergency department a history and physical had not been completed by the physician.
*Care plans were completed and readily accessible for review eight of ten sampled patients (4, 9,10, 11, 12, 13, 14, 15, 16, and 19 who had been discharged from the facility for thirty days or greater.
Findings include:

1. Review of four emergency room records revealed there was a form for the history and physical for patients 21, 22, 23, 24, but they had not been completed.

Interview with the health information manager (HIM) on 06/19/19 at 1:32 p.m. confirmed no history and physical had been completed for patients 21,22,23, and 24. Further interview revealed if the form was blank it had not been done.



32355

2. Review of patient 19's medical record revealed he had been admitted to the emergency room on 3/23/19 and on 3/25/19.
*There was no documentation to support a history and physical had been completed by the physician:
-During his stay in the emergency room.
-Prior to his admittance into the acute care setting.
*The surveyor was not able to access his care plan for review during his stay in the facility.

Medical record review and interview on 6/19/19 at 10:45 a.m. with the director of nursing (DON) regarding patient 19 revealed she:
*Confirmed there was no documentation to support the physician had completed a history and physical on the patient:
-During his stay in the emergency room.
-Prior to his admittance into the acute care setting.
*Agreed the physician should have completed a history and physical on the patient when he was admitted into the emergency room and then into the acute care setting.
*Had completed medical record review and audits on the patients admitted into the facility.
-Those audits had to be completed and reported on within thirty days of the patient's stay.
*Had not been aware the care plans were not accessible for review after thirty days.
*Agreed those care plans were a part of the patient's medical record and should have been accessible for review along with the rest of the chart.



26180

3. Review of patient 4's electronic medical record (EMR) revealed:
*She was admitted on 5/23/19 into swing bed.
*There was not a H and P in her chart when she was admitted.

Review of patient 9's EMR revealed:
*He was admitted on 11/27/18 and discharged on 11/30/18.
*The care plan was not available or accessible in the EMR.

Review of patient 10's EMR revealed:
*She was admitted on 11/16/18 and discharged on 11/23/18.
*The care plan was not available or accessible in the EMR.
*A discharge summary had not been completed.

Review of patient 11's EMR revealed:
*She was admitted on 10/7/18 and discharged on 10/8/18.
*The care plan was not available or accessible in the EMR.
*A discharge summary had not been completed.

Review of patient 12's EMR revealed:
*He was admitted on 12/6/18 and discharged on 12/7/18.
*The care plan was not available or accessible in the EMR.
*A discharge summary had not been completed.

Review of patient 13's EMR revealed:
*She was admitted on 12/16/18 and discharged on 12/18/18.
*The care plan was not available or accessible in the EMR.

Review of patient 14's EMR revealed:
*She was admitted on 2/12/19 and discharged on 2/15/19.
*The care plan was not available or accessible in the EMR.

Review of patient 15's EMR revealed:
*She was admitted on 1/17/19 and discharged on 1/21/19.
*The care plan was not available or accessible in the EMR.

Review of patient 16's EMR revealed:
*She was admitted on 3/4/19 and discharged on 3/14/19.
*The care plan was not available or accessible in the EMR.

4. Interview on 6/18/19 at 11:00 a.m. with the HIM confirmed:
*All medical records should have H and Ps completed when a patient was admitted into acute care.
*A Discharge Summary should have been completed when the patient discharged.
*When a patient transitioned into the Swing bed an admission should have been completed by the physician.
-Sometimes the physician would complete an admission into the swing bed but not discharge the patient from acute care.
-That should not have happened, but it had.
*She confirmed there were records that were missing.
*After checking with their information technology (IT) support they discovered care plans of patients who had been discharged over thirty days ago were not accessible in the EMR.
-That was a glitch in their EMR they had not been aware of until this survey.

Review of the provider's August 2018 Medical Records policy revealed:
*The following documents would be part of the inpatient and swing beds medical record:
-History and physical.
-Discharge summary.
*It did not include a care plan as part of the medical record.

Review of the provider's August 2002 Documentation policy revealed:
*"It is the policy of this facility that documentation of all nursing care, observations, assessments, treatments and effects will be written by an authorized professional. All documentation is expected to be legible, accurate, understandable, timely, pertinent, and held in confidence.
*Procedure included:
-5. Comprehensive care plan."

Based on record review, interview, and policy review, the provider failed to ensure the registered dietician (RD) had signed and dated his nutritional assessments for three of three sampled patients (2, 3, and 8). Findings include:

1. Review of patient 2's medical record revealed:
*An admission date of 6/13/19.
*Her diagnoses included: diabetes, obesity, renal insufficiency, congestive heart failure, and chronic obstructive pulmonary disease.
*She had required a nutritional assessment to have been completed by the RD.
*On 6/15/19 the RD completed a nutrition assessment for the patient.
*The assessment was not signed, dated, or timed by the RD to support:
-When he had completed the assessment.
-He had been the one to have completed that assessment on the patient.

2. Review of patient 3's medical record revealed:
*An admission date of 6/16/19.
*His diagnoses included: complicated urinary tract infection, left flank pain, right lower abdominal pain, Alzheimer's, dementia, and reflux.
*His nutritional intakes had been poor, and he required a nutritional assessment to have been completed by the RD.
*On 6/17/19 the RD completed a nutritional assessment for the patient.
*The assessment was not signed, dated, or timed by the RD to support:
-When he had completed the assessment.
-He had been the one to have completed that assessment on the patient.




26180

3. Review of patient 8's EMR revealed:
*He was admitted on 8/13/18.
*His diagnosis included: heart failure, insulin dependent diabetes mellitus, depression, hypertension, and cellulitis.
*He was on a 2000 American Dietetics Association diet with thin liquids.
*A Nutrition Progress note/assessment was completed on 8/14/18.
-It was not signed or dated.

Interview on 6/18/19 at 3:30 p.m. with the health information manager (HIM) revealed:
*She confirmed patient 8's nutritional progress note/assessment had not been signed or dated.
-They could not say who had completed that assessment.
*They had identified awhile back that professionals were not signing and dating their documents.
-They had changed their system to ensure each page of all assessments were signed and dated.
-They realized that was time consuming, and they thought the problem had been resolved.
-She was unsure if anyone was monitoring it anymore but agreed it was still not being done.

Surveyor: 32355
4. Interview on 6/19/19 at 10:40 a.m. with the director of nursing (DON) regarding the above patients revealed she:
*Was not aware the nutritional assessments had not been signed, dated, and timed upon the completion of them by the RD.
*Agreed they should have been.

5. Review of the provider's August 2002 Documentation policy revealed "Each entry will be written in black ink, dated, and individually signed using name and title."