HospitalInspections.org

A. Based on document review, observation, and interview, it was determined that for 3 of 3 staff (Physical Therapist/E #3, Physical Therapy Technician/E #4, and Nurse Practitioner/E #5), the Hospital failed to ensure that a Registered Nurse supervised and evaluated the care of each patient, by failing to ensure that staff follow isolation precautions and wear appropriate PPE (personal protective equipment) when caring for patients on isolation.

Findings Include:

1. On 8/4/2021, the Hospital's policy titled, "...D. Care considerations related to patient transport and use common areas....5. If a patient must leave his or her room...ensure that precautions are maintained during transfer...i. PPE should be donned by the receiving staff at the new location...6. Once a patient reaches his or her destination, the PPE worn by employees while caring for that patient should match what would be worn if the patient were in the room on the nursing unit...Transmission-Based Precautions" dated 6/2019, was reviewed. The policy required, "...E Precaution-Specific Expectations: Note: Standard precautions are followed at all times even when transmission-based precaution are in place. 1. Contact Precautions...b) gloves c) Gowns - Don a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient..."

2. On 8/4/2021, Pt. #5's clinical record was reviewed. Pt. #5 was admitted on 6/21/2021 with a diagnosis of acute and chronic respiratory failure with hypoxia. The physician order, dated 6/22/2021, included an order to place patient on contact precautions (sputum culture- Pseudomonas aeruginosa carbapenem resistant). Pt. #5 also had an order, dated 8/4/2021 at 8:52 AM, for MDRO/contact precautions for clostridium difficile (stool) - present upon admission.

3. On 8/4/2021, Pt. #10's clinical record was reviewed. Pt. #10 was admitted on 7/29/2021 with a diagnosis of sepsis (serious infection). The physician order, dated 7/29/2021, included an order for MDRO/contact precautions for clostridium difficile (stool) - present upon admission.

4. On 8/4/2021 at 11:26 AM - 11:40 AM, an observational tour was conducted of the physical therapy room. Pt. #5, Pt. #10, the Physical Therapist (E #3), the Physical Therapy Technician (E #4), and the Advance Practice Nurse (E #5) were in the physical therapy room.
-E #3 was sitting on a chair directly in front of Pt. #10, assisting with therapy, without wearing an isolation gown.
-E #3 then went across the room to Pt. #5, placed a safety belt around Pt. #5's waist, assisted Pt. #5 to a standing position, and stood beside Pt. #5 for support. E #3 did not wear an isolation gown while assisting Pt. #5.
-E #4 removed Pt. #5's urinary catheter bag from the wheelchair without wearing gloves. E #4 assisted Pt. #5 to a standing position, and stood beside Pt. #5 for support. E #4 did not wear an isolation gown while assisting with Pt. #5.
-E #5 examined Pt. #10 and Pt. #5, respectively, without wearing a gown during the examination.

5. On 8/4/2021 at 11:40 AM, an interview was conducted with the Physical Therapist (E #3). E #3 stated that she is aware of the patients' contact isolation precautions. E #3 stated that she would normally wear an isolation gown, but she did not wear an isolation gown with the patients on contact isolation because the patients wear clean gowns when coming to physical therapy.

6. On 8/4/2021 at 2:00 PM, an interview was conducted with the Infection Control Coordinator (E #6). E #6 stated that all staff should wear the required PPE when caring for patients on isolation.

B. Based on document review and interview, it was determined that for 2 of 5 (Pt. #1 and Pt. #4) clinical records reviewed for wound care, the Hospital failed to ensure that a Registered Nurse supervised and evaluated the care of each patient, by failing to ensure that wound care was performed as prescribed.

Findings include:

1. On 8/4/2021, the Hospital's policy titled, "Clinical Guidelines for Pressure Injury" dated 6/2019, was reviewed. The policy required, "...8. Frequency of wound dressing change is dependent upon various clinical indicators. Examples include but not limited to: a. Physician order b. dressing integrity c. skin integrity d. incontinence."

2. On 8/4/2021, Pt. #1's clinical record was reviewed. Pt#1 was admitted on 4/20/2021, with diagnoses of ventilator dependent respiratory failure, sinus bradycardia status post pacemaker placement, autonomic dysregulation, and history of aspiration pneumonia, pressure injury sacrum extending to bilateral buttocks present on admission, pressure injury left chest, pressure injury mid back stage III, pressure injury right elbow, and tracheostomy wound.
The Physician order, dated 4/21/2021 and 4/26/2021, included the following wound care orders:
-Sacrum extending to bilateral buttocks (cleanse wound with wound cleanser, apply alginate and medihoney daily and as needed)
-Midback (cleanse with wound cleanser and apply hydrocolloid every three days)
-Left chest (cleanse wound with wound cleanser and apply xeroform daily)
The clinical record lacked documentation that Pt. #1 had daily wound care and dressing changes on the following dates: 4/27/2021 - 4/30/2021, 5/3/2021 - 5/5/2021, 5/10/2021, 5/12/2021, 5/14/2021, 5/17/2021, 5/19/2021, 6/3/2021, 6/7/2021, 6/8/2021, 6/10/2021, and 6/11/2021.

3. On 8/4/2021, Pt. #2's clinical record was reviewed. Pt#2 was admitted on 7/17/2021, with diagnoses of chronic respiratory failure on vent, G-tube feeding, diabetes mellitus, CAD status post stent placement.
The Physician order, dated 7/19/2021, included the following wound care orders:
-Left shin (cleanse wound with wound cleanser, apply dressing with betadine and leave open to air daily)
-Left iliac crest (cleanse wound with wound cleanser, apply dressing with alginate and medihoney daily)
-Left heel (cleanse wound with wound cleanser, apply dressing with betadine and leave open to air daily).
The clinical record lacked documentation that Pt. #2 had wound care and dressing changes on 7/26/2021 and 7/27/2021.

4. On 8/4/2021, Pt. #4's clinical record was reviewed. Pt#4 was admitted on 5/30/2021, with diagnoses of acute on chronic failure status, severe anoxic brain injury, cerebral hemorrhage, seizures, and severe pulmonary stenosis. Pt. #4 was admitted with a pressure ulcer to the sacrum.
The Physician order, dated 5/31/2021, included the following wound care orders:
-Sacrum extending to the bilateral buttocks (cleanse wound with wound cleanser, and apply dressing with hydrocolloids three times per week - Monday, Wednesday, and Friday).
-Left ear (cleanse wound with wound cleanser and apply dressing with betadine every night)
-Perianal (cleanse wound with wound cleanser and apply hydrophilic (zinc oxide based cream) wound dressing every 12 hours).
On 6/7/2021, the wound care and dressing changes to the sacrum and the perianal area were not performed as prescribed.
On 6/8/2021, Pt. #4 did not have any wound care or dressing changes performed.

5. On 8/5/2021 at 10:16 AM, an interview was conducted with the Wound Care Coordinator (E #3). E #3 stated that it is the responsibility of the bedside nurse to perform wound care and dressing changes as prescribed. E #3 stated that the responsibility of wound care and dressing changes was recently shifted to the bedside nurse, and she is not sure if the changes were conveyed to the bedside nurses and the dressing were not being done.

C. Based on document review and interview, it was determined that for 2 of 8 (Pt. #2 and Pt. #3) clinical records reviewed for turning and repositioning, the Hospital failed to ensure that a Registered Nurse supervised and evaluated the care of each patient, by failing to ensure that each patient was turned and repositioned every two hours, per policy.

Findings include:

1. On 8/4/2021, the Hospital's policy titled, "Clinical Guidelines for Pressure Injury" dated 6/2019, was reviewed. The policy required, "...5. Standards interventions for all patients can included but not limited to: c. repositioning orders (minimum Q2* turns) [every two hours]...iii. Considerations for patients requiring Q1 -Q2 [every 1 - 2 hours] turn and repositioning: patient unable to turn and reposition self...skin is moist or at risk for friction/shear injury..."

2. On 8/4/2021, Pt. #2's clinical record was reviewed. Pt#2 was admitted on 7/17/2021, with diagnoses of chronic respiratory failure on vent, G-tube feeding, diabetes mellitus, CAD [coronary artery disease] status post stent placement.
-Pt. #2's clinical record lacked documentation that Pt. #2 was turned and repositioned at any time from 7/20/2021 -7/28/202 and on 7/31/2021.

3. On 8/4/2021, Pt. #3's clinical record was reviewed. -Pt#3 was admitted on 6/5/2021, with diagnoses of multi-territorial age variable infarcts, severe encephalopathy, autonomic dysreflexia/neuro storming, acute respiratory failure, acute PE [pulmonary embolism], MSSA and Klebsiella [serious infection] pneumonia, severe tongue swelling, and type 1 diabetes mellitus. Pt. #3 was discharged on 7/23/2021.
-Pt#3's admitting orders, dated 6/5/2021, included an order to reposition every 2 hours.
-Pt. #3's clinical record lacked documentation that Pt. #3 was turned and repositioned at any time from 7/6/2021 - 7/9/2021.

4. On 8/5/2021 at 10:16 AM, an interview was conducted with the Wound Care Nurse (E #3). E #3 stated that patients should be turned and repositioned every two hours, unless there is a special order not to turn the patient. E #3 stated that if a patient is not turned and repositioned every two hours, there is an increased potential for development and worsening of pressure injuries.


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D. Based on document review and interview, it was determined that for 1 of 4 patients (Pt#3) clinical records reviewed for patients with PICC (peripherally inserted central catheter) lines, the Hospital failed to ensure that the Registered Nurse supervised and evaluated the care for each patient by ensuring that the PICC line was assessed according to policy.

1. On 8/5/2021, the Hospital's policy titled, "CORE: Central Line Placement, Maintenance and Dressing Change" was reviewed and indicated, " ...5. Ongoing assessment daily and with dressing change of the IV site. Assess for complications (signs of infection and/or pain at site) and measurements as indicated. Notify MD of drainage, redness, pain, warmth, swelling, and/or patient develops fever ..."

2. On 8/4/2021 Pt. #3's clinical record was reviewed. Pt#3 was admitted on 6/5/2021, with diagnoses of multi-territorial age variable infarcts (stroke), severe encephalopathy (disease of the brain), acute respiratory failure, acute PE (pulmonary embolism), pneumonia, severe tongue swelling. Pt#3 had a central line (PICC) in her right arm that was inserted on 6/7/2021, removed on 6/22/2021 and a new line inserted on 6/22/2021. Admitting orders indicated, "document PICC line necessity; verify and document dressing condition with date and initials; verify and document IV tubing labeled with date, time and initials ... q [every] shift ..." Pt#3's chart lacked documentation of the central line being assessed on the following dates: 6/11, 6/12, 6/16, 6/17, 6/26, 6/27, 6/28, 7/3, 7/5, 7/7, 7/10, 7/11, 7/14, 7/17, 7/18, and 7/19.

3. On 8/5/2021 at approximately 12:45 PM, an interview was conducted with the Director of Nursing and Clinical Services (E#2). E#2 stated that PICC lines should be assessed every shift.

E. Based on document review and interview, it was determined that for 2 of 4 (Pt#1 and Pt#2) clinical records reviewed for patients with PIV (peripheral intravenous) lines, the Hospital failed to ensure that the Registered Nurse supervised and evaluated the care for each patient by ensuring that the PIV line was assessed according to policy.

1. On 8/5/2021, the Hospital's policy titled, "CORE: Short Peripheral IV Site Placement, Maintenance and Dressing Change" was reviewed and indicated, " ...The Hospital Division has identified the institute for Healthcare Improvement Central Line Bundle as a Best Clinical Practice Standard ..." The Central Line Bundle indicated, "document PICC line necessity, verify and document dressing condition with date and initials, verify and document IV tubing labeled with date, time and initials ...q [every] shift ..."

2. On 8/4/2021, Pt. #1's clinical record was reviewed. Pt#1 was admitted on 4/20/2021, with diagnoses of ventilator dependent respiratory failure. Pt#1 had a peripheral midline IV (intravenous, the administration of substances into the body through a vein) to his left upper forearm that was placed on 6/10/2021. Pt#1's chart lacked documentation of an assessment of the midline IV on 6/14/2021, 6/15/2021, 6/16/2021, and 6/20/2021.

3. On 8/4/2021, Pt. #2's clinical record was reviewed. Pt#2 was admitted on 7/17/2021, with diagnoses of chronic respiratory failure on vent, diabetes mellitus, CAD (coronary artery disease) status post stent placement. Pt#2's had a midline peripheral IV. Pt#2's chart lacked documentation of an assessment of the midline IV on 7/25/20221, 7/26/2021, 7/27/2021, and 7/28/2021.

4. On 8/4/2021, at approximately 12:45 PM, an interview was conducted with the Director of Nursing and Clinical Services (E#2). E#2 stated that midline peripheral IV's should be assessed on a daily basis.