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Based on record reviews and interview, the hospital failed to ensure that the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failing to individualize the patient's nursing care plan to include all the patient's medical diagnoses for which the patient was being treated, and failing to update/revise the plan of care when the patient's condition changed for 5 of 5 (#1-#5) sampled patient medical records.
Findings:

Review of the Hospital policy titled, Patient Assessment/Reassessment, Policy Number OrgClin/031, provided by S2RegMgt as the hospital's policy for care planning, revealed the following: Qualified members of the patient's treatment team identify treatment priorities that will be addressed in the Interdisciplinary Plan of Care. Less urgent needs may not be included in the active plan....Ongoing reassessment is done throughout the course of the patient's stay with changes to the plan of care as appropriate....


Patient #1
Review of the medical record for Patient #1 revealed the patient was admitted to the hospital on 07/05/16 with a diagnosis of Sepsis and Cellulitis of the Left Foot. Review of the physician's progress notes dated 07/05/16 revealed the following: Diabetic foot ulcer: fairly deep; vascular surgery consulted ....Diabetes Mellitus Type 2: uncontrolled, start Lantus.

Review of the physician orders from admission to 07/12/16 revealed finger stick blood glucose testing was ordered before meals and at bedtime with sliding scale insulin administration. Further review of the physician orders revealed multiple changes in the insulin dose and sliding scale were ordered.

Review of the Blood Glucose Flowsheet from admission to 07/12/16 revealed the patient received multiple doses of insulin every day of the current hospital stay.

Review of the plan of care from admission to 07/12/16 revealed no documented evidence that the patient's Diabetes Mellitus, uncontrolled was included in the plan of care. There was no documented evidence that Diabetes Mellitus was an identified problem for this patient and there were no identified goals or interventions.

In an interview on 07/12/16 at 3:15 p.m., S5NE (Nurse Educator) reviewed the EMR with the surveyor and confirmed the patient's problem of uncontrolled Diabetes Mellitus was a current problem for the patient and should have been included in the plan of care. S5NE confirmed the patient's Diabetes Mellitus was not included in the patient's plan of care.


Patient #2

Review of the medical records for Patient #2 revealed an admission date of 5/21/16 with an admission diagnosis of Acute Urinary Tract Infection with Dehydration.

Review of Patient #2's physician progress notes, dated 5/27/16, revealed the patient developed steroid induced Hyperglycemia requiring medical management with sliding scale insulin administration on 5/27/16.
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Review of the Care Plans for Patient #2 revealed the plan of care had not been updated to reflect the patient's additional diagnosis of steroid induced Hyperglycemia.



Patient #3
Review of the medical record for Patient #3 revealed the patient was a 91 year old admitted to the hospital on 05/11/16 with diagnoses of Pneumonia and Hypoxemia. Review of the record revealed a sputum culture report dated 05/14/16 that indicated the sputum contained MRSA. Review of the record revealed contact precautions were implemented on 05/14/16 at 7:00 a.m.

Review of the plan of care for Patient #3 revealed no documented evidence of any identified problems, goals, or interventions to address the patient's primary diagnoses of Pneumonia and Hypoxemia. Further review of the care plan revealed no documented evidence that the care plan was updated to include the patient's diagnosis of MRSA in the sputum and contact precautions.

In an interview on 07/13/16 at 12:16 p.m., S5NE reviewed the EMR with the surveyor and confirmed the plan of care did not include the identified problem of Pneumonia and Hypoxemia, which were the patient's primary diagnoses and reason for admission. S5NE confirmed there were no goals or interventions related to the primary diagnosis, and confirmed the care plan was not updated when the contact precautions were implemented for MRSA infection in the respiratory tract.


Patient #4
Review of Patient #4's medical record revealed an additional identified active diagnosis of Diabetes Mellitus. Additional review revealed the patient was receiving Lantus Insulin, 22 units subcutaneously every HS (Hour of sleep).

Review of Patient #4's plan of care revealed Pain, Knowledge Deficit, and Impaired Gas Exchange were identified as problems. Further review revealed Diabetes Mellitus was not identified as an active problem on the patient's care plan.

In an interview on 7/12/16 at 4:12 p.m. with S20RN, he confirmed Patient #4 required medical management of her Diabetes Mellitus. S20RN indicated the focus of Patient #4's care on this admission was respiratory status and not Diabetes Mellitus. He indicated addressing too many issues on patient care plans diluted the focus of care. S20RN further indicated patient care plans should be focused on the patient's admission diagnosis.



Patient #5
Review of the medical record for Patient #5 revealed the patient was a 92 year old admitted to the hospital on 07/05/16 with diagnoses of Atrial Fibrillation with Rapid Ventricular Response, C.difficile Colitis and Volume Depletion (Dehydration).
Review of the plan of care revealed there was no documented evidence that the patient's admitting/primary diagnoses of Atrial Fibrillation and Dehydration were included in the plan of care.

In an interview on 07/13/16 at 3:30 p.m., S5NE reviewed the EMR with the surveyor and confirmed the plan of care did not include the primary diagnoses of Atrial Fibrillation and Dehydration. S5NE stated the nursing staff could have chosen the template for decreased cardiac output to address the Atrial Fibrillation. She stated the nursing staff could have chosen Deficient Fluid Volume to address the patient's Dehydration.



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Based on record review, observation, and interview, the hospital failed to ensure the infection control officer developed a system for controlling infections and communicable diseases of patients and personnel. This deficient practice is evidenced by staff failing to use an EPA-approved, spore killing disinfectant for cleaning re-usable patient care equipment that had been used in the care of a patient with C.difficile infection who was on Contact Precautions-Plus.

Findings:

Review of the Hospital policy titled, Isolation Precautions revealed no documented evidence of a provision for the cleaning of reusable patient care equipment for patients on Contact Precautions-Plus. There was no documented evidence of any provisions for cleaning of equipment that had been used for patients on Contact Precautions for C.difficile.

According to CDC Guidelines room surfaces and equipment should be disinfected with an EPA-approved, spore killing disinfectant (such as bleach) where C.difficile patients are treated.

Review of Patient #5's medical record revealed the patient was on Contact Precautions Plus for C. difficile.

On 7/11/16 at 3:49 p.m. an observation was made of Patient #5's room. The signage on the patient's room indicated the patient was on Contact Precautions-Plus.

On 7/11/16 at 3:50 p.m. an observation was made of S24EEG removing PPE after performing an EEG on Patient #5. She was observed wrapping the "EEG head box" in paper towels after performing an EEG on Patient #5. She placed the paper towel wrapped "EEG head box" in the drawer of the portable EEG machine. S24EEG indicated she had wiped down her equipment with the disinfectant wipes located in Patient #5's room. She further indicated she was going to disinfect the equipment when she returned to her department.

On 7/11/16 at 3:55 p.m. an observation was made of the label on the disinfectant wipes located in Patient #5's room. The disinfectant wipes being used for wiping down equipment that had been brought into the patient's room did not contain Hypochlorite and the label did not indicate the disinfectant wipes were effective against C. difficile.

In an interview on 7/11/16 at 3:57 p.m. with S4NM, she confirmed the disinfectant wipes being used to disinfect equipment used in Patient #5's room did not contain Hypochlorite and was not effective against C. difficile.

On 07/11/16 at 4:00 p.m., an observation was made of S10CNA rolling the blood pressure machine into the room of Patient #5, who was on Contact Precautions-Plus. In the basket of the machine was an electronic thermometer, a pulse oximeter and a blood pressure cuff. S10CNA was observed to use the equipment to assess the patient's blood pressure, temperature, and oxygen saturation level. S10CNA was observed to remove a disinfectant wipe from the container in the patient's room and clean the pulse oximeter, blood pressure machine and cord, and the thermometer after use.

In an interview on 07/11/16 at 4:10 p.m., S10CNA confirmed she had cleaned the face of the blood pressure machine, the cord, the pulse oximeter, and the thermometer with a wipe retrieved from the container of wipes that was in the patient's room. S10CNA stated she did not use the blood pressure cuff that was in the basket of the blood pressure machine when she assessed Patient #5's blood pressure. S10CNA confirmed she had brought the blood pressure cuff in the basket of the blood pressure machine into Patient #5's room and she had not cleaned it.

In an interview on 07/11/16 at 4:15 p.m., S4NM, who was present for the observation, confirmed the wipes used by S10CNA to clean the equipment taken into Patient #5's room had not been cleaned with a wipe that contained Hypochlorite. S4NM confirmed Patient #5 was on Contact Precautions-Plus due to C.difficile and the patient care equipment had not been cleaned with the appropriate wipe.



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