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Based on observation, staff interview and review of medical records and documents, it was determined that the facility failed to ensure compliance with the provision of nursing services by failing to:
(1) Document a full and adequate description of nursing care and interventions provided for a patient with decubitus ulcer. This was evident in one (1) of three (3) related medical records that were reviewed.
(2) Develop and implement guidelines to govern compliance with removing/returning medications to the pharmacy, for patients that have been discharged from the facility.
(3) Develop and implement guidelines to ensure compliance with infection control practice for the prevention and control of communicable diseases.

Findings:

(1) Tour of the 2 North unit on 2/05/15 at 2:35 PM revealed:

Patient MR #1, a 49 year old (y/o) male, was admitted to the facility on 1/20/15, with Chief complaint of Breathing Difficulty.

The physician's Admission History & Physical, entered on 1/21/15 at 7:10 PM, indicated: obese male, alert, oriented to person, place and time (oriented x3); Past Medical History (PMH) of Diabetes Mellitus, Peripheral Vascular Disease, Hypertension, Anemia of Chronic Disease, recurrent Urinary Tract Infection, Chronic Kidney Disease Stage 3, Gout, Sacral Decubitus Ulcer Stage III, pressure ulcers on right heel and sacrum; Decubitus ulcers do not appear to be infected. The Treatment Plan included evaluation by wound care nurse and there is a documented physician order on 1/21/15 for: Consult wound care for Sacral Stage 3 and Right (RT) Heel Ulcer.

The Admission Profile, entered by the Registered Nurse (RN) on 1/21/15 at 11:34 AM, included a Skin Assessment, which revealed Sacral Decubitus Ulcer; a Braden Risk Assessment (a tool used to assess a patient's risk of developing a pressure ulcer by examining six criteria - sensory perception, moisture, activity, mobility, nutrition, and friction and shear) identified a Risk Score of 16 (the Braden Risk Assessment score scale is as follows: Very High Risk - total score 9 or less; High Risk - total score 10-12; Moderate Risk - total score 13-14; Mild Risk - total score 15-18; and No Risk - total score 19-23); and the Nutrition Screening identified the presence of Actual/Potential skin breakdown.

The Nursing Care Plan was developed on 1/21/15 and the documented Plan/Interventions for Skin Integrity included, "to initiate the skin/wound protocol". However, there is no consistent documentation in "Assessment and Cares" to determine that the protocol was fully implemented.

There is no ongoing documentation of a wound description after 1/21/15, when the RN documented: (a) Pressure Ulcer Stage IV, Sacral Spine, 4 centimeter x 4 centimeter x 2 centimeter (4 cm x 4 cm x 2 cm), cleansed with normal saline, and dressing applied; and (b) Pressure Ulcer Stage III, Right Heel, 4 cm x 4 cm, dressing appearance was dry and intact.

There is inconsistent staging of the pressure ulcer(s) as evidenced by the documentation on 1/22/15 through 1/25/15, and 2/4/15 and 2/5/15, which described the Pressure Ulcer, Sacral Spine as Stage IV,however, this Pressure Ulcer was described as Stage III on 1/26/15 through 2/3/15.

Wound treatment documented by the RN on 1/21/15 and 1/22/15 states "cleanse with normal saline and sterile dressing applied". This does not conform to the facility's protocol for treatment of Stage Three and Stage Four Pressure Ulcers, which requires the use of Multidex powder/gel then Covaderm/Polyderm Plus dressing.

The RN documented on 1/23/15 that dressing was applied by wound management. However, there is no documentation of this treatment in the medical record.

Dressing appearance "dry and intact" is repeated from 1/25/15 through 2/05/15, but there is no documentation of the wound care treatment that was provided to the pressure ulcers.

The initial wound assessment by the wound consultant was entered on 1/28/15, approximately seven (7) days after the physician's order. The assessment indicated:
· Wound 1 - Patient with post-surgical wound to the Rt Heel 5 cm x 5 cm x 1 cm. Wound care with Multidex powder. Covered with Kalginate and wrapped with kling is documented. Recommendation: change dressing every other day.
· Wound 2 - Pressure ulcer, Sacrum, Stage 4, 3 cm x 3 cm x 3 cm. Wound care with Multidex powder. Covered with loosely packed Kalginate and covered with Polyderm is documented.
Reassessments with wound treatment by the wound consultant was documented on 1/29/15, 2/04/15 and 2/05/15, with the recommendation for daily dressing change to the sacral decubiti. However, there is no documentation that the wound consultant communicated the findings and recommendations to the health team members and that the recommendations were implemented.

It was also noted that this patient did not receive a nutrition consult.

These findings were acknowledged by Staff #1 who was present at the time of the review of the Electronic Medical Record (EMR) on 2/5/15 and 2/6/15. Staff #1 stated the RN will initiate pressure ulcer treatment as per facility's protocol and will request a wound consult. The physician will order the consult and the wound care consultant will make the recommendation for wound treatment.

The facility's policy: Skin Integrity, Pressure Ulcer Prevention and Treatment, revealed:
(A) The Registered Nurse (RN) is responsible to provide initial and ongoing assessment of skin risk for each patient.
(B) If a pressure ulcer is identified, document assessment findings and measurements in EMR, Assessment and Cares.
(C) On admission, a nutritional screen will be completed in the EMR and nutrition consult ordered from the screening if applicable. Request a nutrition consult for all patients at risk for pressure ulcer or with actual pressure ulcer.
(D) Treatment of Pressure Ulcers includes: (a) Record wound measurements Monday/Wednesday/Friday (M/W/F) and on discharge; and (b) Stage Two, Stage Three and Stage Four Pressure Ulcers, cleanse with normal saline, apply Multidex powder/gel then Covaderm/Polyderm, plus dress daily or pro re nata (prn - as the circumstance arises).

There is no documentation in the medical record to indicate full compliance by the staff, with with the above noted facility policy requirements for pressure ulcer prevention and treatment.

At interview, on 2/06/15 at approximately 3:20 PM, Staff #2 stated that the initial wound assessment was completed on 1/23/15, and not on 1/28/15 - the wrong date was documented. Her records showed that she reassessed the patient on 1/26, 1/29, 1/30, 2/3, 2/4, and 2/6/15 and that wound care treatment was provided, but it was not documented. Staff #2 stated, she does not always document the wound treatment because she is required to document wound assessment and treatment initially and weekly. The facility does not have a policy to govern this practice as stated by the wound consultant, and there are no policies / guidelines governing referrals, evaluations, treatments and recommendations made by the Wound Care Team consult.


(2) Tour of 2 North on 2/05/15 at approximately 3:15 PM revealed:

The Medication Refrigerator, located in the Medication Room had medications for patients who were discharged from the facility.
1. Patient MORN, had two (2) doses of Estrogen IV medication, both dated 1/27/15.
2. Patient MORN had Hepatitis B Vaccine medication, dated 1/28/15.
3. Patient MJ had Novolog medication dated 11/27/14. Staff #3 who was present during the tour, stated this medication was not from the pharmacy; the medication was patient's "home" medication that was held for the patient and should have been returned to the patient when he was discharged.
4. Patient MRN00949999 had two (2) doses of Latanoprost eye drop medication, both dated 12/16/14.
5. Patient MRN00886398 had Latanoprost eye drop medication, dated 11/25/14.

Staff #3, acknowledged the presence of these medications and confirmed that the patients were all discharged. Staff #3 stated that the temperature of the refrigerator is monitored by pharmacy, but acknowledged that the nurses access the refrigerator at least daily and that they should be aware that medication belonging to discharged patients was still in the refrigerator. Staff #3 stated these medications should have been returned to the pharmacy.

The facility's policy: Drug Storage, does not provide guidelines for the handling of medications for patients who are discharged from the facility. There are guidelines for "Expired Medication" which states: "Any medication that has passed its expiration date shall be removed and placed in a bag or box clearly marked 'Expired Drugs'. Expired medication are physically segregated from in-date medications and cannot be dispensed."

At interview with Staff #4 on 2/06/15 at 10:15 AM, Staff #4 stated the Temperature Logs for the refrigerators are kept by the pharmacy. Staff #4 stated that the Pharmacy Technician performs rounds and records the temperature daily, delivers new medications, and checks for discontinued or expired medications. Staff #4 added that the nurses will pull the medications upon discharge of the patient.

The facility failed to ensure that medications for patients who were discharged, were removed from the unit and returned to the pharmacy.


(3) During a tour of the 6 North unit on 2/06/15 at approximately 2:30 PM, Patient MR #2 was in an isolation room and a visitor was observed not wearing a mask. The visitor was seen sitting in a chair approximately 2 feet from the patient. In order to rule out Tuberculosis this patient was admitted to a room with a hepa filter on 2/5/15. Tuberculosis is an airborne infectious disease.

Interviews with Staff #5 and Staff #6 were conducted on 2/06/15 at approximately 2:30 PM. Staff #5 stated that she had spoken to the patient's family at 10:00 AM, advising the family that they had to wear the mask while visiting their mother in the airborne isolation room. Staff #5 further stated that the family verbalized that they would comply and wear the mask during their hospital visit. Staff #5 stated that she demonstrated to the patient's family how to put on the mask, that the patient's family then "as a drill" demonstrated how to put on the mask, and that they also agreed to wear the mask. Staff #5 acknowledged that visitors should adhere to hospital procedures. The surveyor asked if the facility had a policy regarding non-compliant visitors, Staff #5 and Staff #6 stated that the facility did not have such a policy.

Staff #6 stated that "it would take a long time before a person can become exposed." Staff #6 further stated "we do not want to restrict visitors because that will make the family very upset." Staff #5 stated that she would talk to the family again.

The facility failed to establish and implement and effective infection control program for the prevention and control of communicable diseases.