HospitalInspections.org

Based on document review and staff interviews, it was determined that the Hospital failed to ensure care was provided as ordered for 2 (Pt #1 and Pt #6) of 10 patients. This has the potential to negatively impact all patients receiving care at the Hospital.
Findings include:
1. The clinical record of Pt #1 was reviewed on 10/17/16. It indicated that Pt #1 was admitted to the hospital on 4/18/16 with the diagnosis of subdural hematoma. The intensive care unit (ICU) Nurse Practitioner (NP) orders included ... " oral care every four hours " ordered 4/18/16 at 8:00 PM. Documentation of oral care completed as ordered was not found for 4/19, 4/20, 4/22, 4/23, 4/24, 4/25, 4/26/16.
2. The clinical record of Pt #6 was reviewed on 10/18/16. It indicated that Pt #6 was admitted to the hospital on 9/7/16 with the diagnosis of pancreatitis. Physician order for oral care to be provided by staff ... "every four hours" was ordered 9/11/16 at 12:00 PM. Documentation of oral care provided for Pt #6 was incomplete on 9/12, 9/16, 9/18, 9/19, 9/20, 9/21, 9/27, 9/30, 10/5, 10/10, 10,12, 10/14, 10/16/16
3. During a interview with the IT (Information Technology)- Nurse (E #11) on 10/20/16 at 11:00 AM, E #11 stated the Director of Nursing is aware of the lack of documentation for both patients.

Based on document review and interview, it was determined for 1 of 6 (Pt #6) patient, the Hospital failed to ensure the patient's plan of care was updated to include isolation education as per policy. This has the potential to effect all patients, visitors, and staff of the facility.

Findings include:

1. Hospital policy titled, "Isolation Guidelines" (review date 03/06/16) required under Procedure A. 2. "Patient Care Staff will be responsible to communicate appropriate transmission-based guidelines: e. To the patient and/or family/responsible party by providing written or verbal education/instruction."

2. Hospital policy titled "Isolation Guidelines: Inpatient" (review date 03/06/16) required under transmission based precautions-contact-common diseases requiring contact precautions: clostridium difficile (C. Difficile)... MRSA (Methicillin Resistant Staphylococcus Aureas)... "In addition to standard precautions: Gowns: A gown will be worn when entering the room. Gowns will be removed prior to leaving the patient's room."

3. The clinical record of Pt. #6 was reviewed on 10/19/2016 at approximately 1:00 PM. Pt. #6 was admitted on 9/7/2016 with the diagnosis of pancreatitis. On 10/17/2016 at 8:47 AM lab results were positive for MRSA (Methicillin Resistant Staphylococcus Aureus) in the tracheal site. On 10/8/2016 at 11:00 AM lab results were positive for C. Difficile (clostridium difficile) Toxin in the stool. The plan of care was not updated indicating required isolation education.

4. An interview was conducted on 10/17/2016 at approximately 11:55 AM with Pt #6. Pt #6 stated he did not receive any education for the reason for isolation.

5. An interview was conducted with Pt #6's uncle on 10/17/2016 at approximately 11:45 AM, whom was visiting at bedside without wearing a gown. The uncle stated, "I visit often and I have not received any information regarding isolation."

6. During an interview on 10/19/2016 at approximately 3:00 with the Senior Vice President and Chief Nursing Officer (E #1). E #1 stated, "Education should have been provided to both the patient and the visitor."