HospitalInspections.org

Based on review of medical records (MR) and facility policy, observations and interviews, it was determined the facility failed:

1. To ensure wound care was provided as ordered by the physician and per policy.
2. To insure wounds were measured per policy.
3. To ensure PICC (Peripherally Inserted Central Catheter) line care was provided as ordered by the physician and per policy.

This affected 4 of 7 wound care (MR #'s 3, 23, 26 and 31)and 3 of 4 PICC lines (MR #'s 3, 32 and 33) and had the potential to affect all patients with wounds and PICC lines.

Findings include:

Policy: PICC Placement and Management

General Instructions: ...2, Arm circumference will be measured at the insertion site.....

Dressing Change: ..The licensed nurse will replace the initial gauze dressing after 24 hours and replaced with a sterile transparent dressing.

Flushing: The PICC line will be flushed before and after intermittent infusions/medication administration by an RN (Registered Nurse). The PICC line will also be flushed twice daily when continuous infusions are present.

Procedure:.....G. Flush with 10 ml (milliliter) of Normal Saline (or 20 ml after lab draws or blood products) using "push-pause" technique.

PICC Routine Care Orders: Flushing:....Flush with 10 cc (cubic centimeters) of Normal Saline and draw a 10 cc waste, (may substitute Heparin Flush 5 cc for sluggish catheter with MD orders).

Assessment: Daily assessment of PICC site and condition should be charted. Daily assessment of ARM CIRCUMFERENCE (PICC ARM).

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Agency Policy: Wound Dressing Change: Nursing Guidelines
Facility/Department/Function: SVS /6000/Nursing Administration
Purpose: To provide consistent treatment procedures for each patient requiring a wound dressing change.
Policy: Wound dressing changes are considered to be aseptic or clean technique and performed as sterile as possible ...
Procedure:
...10. Remove soiled dressings
11. Place soiled dressings, gloves in proper container
12. Wash hands
13. Don clean gloves
14. Continue dressing change as ordered
15. Wash hands and change gloves between each wound when there are multiple areas ...


1. MR # 3 was admitted on 3/19/12 with diagnoses including Altered Mental Status, Urinary Tract Infection and Parkinson's Disease.

A review of the medical record revealed a PICC line was placed on 3/20/12.

The PICC Routine Care Orders included, "Flushing: ... Flush with 10 cc (cubic centimeters) of Normal Saline and draw a 10 cc waste, (may substitute Heparin Flush 5 cc for sluggish catheter with MD orders).

Assessment: Daily assessment of PICC site and condition should be charted. Daily assessment of ARM CIRCUMFERENCE (PICC ARM)."

A review of the nurse flowsheets from 3/20/12 to 3/28/12 revealed documentation the PICC line was flushed, however, did not specify the amount or solution used to flush.

A review of the nurse flowsheets from 3/22/12 to 3/28/12 revealed no daily PICC line arm circumference measurements.

2. MR # 32 was admitted on 5/9/12 with diagnoses including Congestive Heart Failure, Hypertension and Alzheimers. This patient expired on 5/11/12.

A review of the medical record revealed a PICC line was placed on 5/10/12.

A review of the nurse flowsheets from 5/10/12 to 5/11/12 revealed the PICC line was flushed, however, did not specify the amount or solution used to flush.

An interview on 7/26/12 at 11:00 AM with Employee Identifier # 1, Director Clinical Excellence, confirmed the above.


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3. MR # 33 was admitted to the facility on 6/11/12 with diagnoses including Need PICC line, Pneumonia, and Left Heel Decubitus.

Review of the Physician Orders dated 6/12/12 revealed orders for the PICC Routine Orders which included:

Flushing:

7. Flush all lumens with 10 cc of Normal Saline every 12 hours even when infusing.

Assessment:

14. Daily assessment of ARM CIRCUMFERENCE (PICC ARM)

a. Measure from the antecubital fossa up 10 cm at the point measure around the arm to get the circumference

b. Compare the baseline arm circ. (circumference), if measurement is greater than 3 cm notify the house supervisor to notify the PICC nurse.

Review of the Progress Note dated 6/12/12 at 7:00 PM, when the PICC line was inserted, revealed an arm circumference of 29 cm.

Review of the Nursing Flowsheet dated 6/17/12 at 10:20 AM revealed an arm circumference of 26 inches. There was no documentation of an arm circumference for 6/13/12, 6/14/12, 6/15/12, or 6/16/12.

Review of the Nursing Flowsheets between 6/12/12 and 6/18/12, when the patient was discharged from the hospital, revealed no documentation the PICC line was flushed with 10 cc of Normal Saline.

An interview with EI # 7, Director of Med-Surg and ICU (Intensive Care Unit) was conducted on 7/27/12 at 1:00 PM who verified the above.

4. MR # 23 was admitted to the facility on 4/4/12 with diagnoses including Chronic Airway Obstruction and discharged on 4/6/12.

Review of the Emergency Nursing Record dated 4/4/12 at 12:01 PM revealed documentation the patient had wounds to the bilateral upper arms from a fall at home.

Review of the Present on Admission note dated 4/4/12 revealed documentation there was no skin breakdown present.

Review of the Skin Tear Thickness Wound order dated 4/4/12 at 6:00 PM revealed a left and right upper arm skin tear. The wound care orders included: clean with normal saline. Pat-dry with 4x4. Apply antibiotic ointment. Cover with Telfa, secure with Kling and paper tape. Change daily.

Review of the Nursing Flowsheet dated 4/4/12 at 4:12 PM revealed documentation the nurse applied vaseline gauze to the left and right arm. There was no documentation of a physician's order for the vaseline guaze.

Review of the Nursing documentation on 7/25/12 revealed no documentation of a wound measurement for the left and right upper arm skin tear nor use of the antibiotic ointment.

5. MR # 26 was admitted to the facility on 5/27/12 and discharged on 5/31/12 with diagnoses including Chronic Obstructive Pulmonary Disease.

Review of the Present on Admission Progress Note dated 5/27/12 at 6:35 PM revealed documentation the patient had multiple bruises and scabs on bilateral lower legs, bilateral knees, bilateral arms, hands and shoulders.

Review of the Nursing Flowsheet dated 5/27/12 at 8:45 PM revealed documentation the patient had scratches/abrasions on the left and right arm, elbow, knee, leg and shoulder.

Review of the Nursing Flowsheet dated 5/28/12 at 7:51 AM revealed documentation the patient had scratches/abrasions on the left and right arm and ankle.

Review of the Nursing Flowsheet dated 5/28/12 at 7:11 PM revealed documentation the patient had scratches/abrasions on the left and right arm and ankle.

Review of the Nursing Flowsheet dated 5/29/12 at 6:44 PM revealed documentation the patient had scratches/abrasions on the left and right arm and ankle.

Review of the Order Confirmation Report dated 5/29/12 at 19:17 revealed the following wound care orders:

Wound Type: Skin Tear
Wound Location: Right leg and Left Arm
Clean/Irrigate with: saline
Pack with: Plain Nu Gauze
Periwound Care: Moisture Barrier
Dress/Cover Wound with: 4x4 gauze
Secure Dressing With: Kerlix

Review of the Nurse documentation between 5/29/12 and discharge on 5/31/12 revealed no documentation of the above wound care.

There was no documentation between 5/27/12 and 5/31/12 of a wound assessment or measurement.

An interview with EI # 8, a Director of Clinical Excellence on 7/26/12 at 11:55 AM verified the above.


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6. MR # 31 was admitted to the facility on 2/10/12 with diagnoses including Seizure Disorder, Metabolic Encephalopathy, Chronic Kidney Disease and Type 2 (two) Diabetes Mellitus.

A review of the medical record revealed Stage 1 (one) Pressure Ulcer Protocol orders dated 2/14/12 at 13:15. The orders were "Granulex spray every 8 hours to Stage 1, spray on gloved hand and apply like a lotion over affected area (soft, spongy skin. Example: heels) Preventative/Pressure Reducing Mattress " .

Review of the Medication Administration Records dated 2/18/12 from 00.00-07.59 and 2/19/12 from 00.00-07.59 and Nursing assessment flowsheets dated 2/18/12 and 2/19/12 revealed no documentation that Granulex had been applied every 8 hours according to physician's orders.

Review of the medical record revealed a triple PICC lumen line was inserted 2/12/12. Physician orders for the care of the PICC included "Flush all lumens with 10cc of Normal Saline Q (every) 12 hours even when infusing " .

Review of the Medication Administration Records and Nursing assessment flowsheets dated 2/12/12, 2/13/12, 2/16/12 and 2/17/12 revealed no documentation of the type and amount of solution used to flush the patient 's PICC line.

An interview was conducted on 7/26/12 at 12:46 PM, with EI # 7, RN, Director of Medical Surgical and Intensive Care Services, who validated the above.

Based on observation, review of policies and procedures and interviews it was determined the facility failed to ensure the staff followed their own standards of practice for hand hygiene. This had the potential to affect all patients served by this facility.

Findings include:

Facility Policy: Hand Washing Hygiene ID-221135

Policy:

Hand washing has been recognized as the single most important preventative measure in decreasing the transmission of infection. Hand washing should be easy and accessible to patients, personnel, and visitors.

Hand decontamination must be performed:...

Before putting on and after removal of protective equipment (gloves, gown, etc.).

After handling contaminated items (specimens, equipment, etc.).


The surveyor observed care in PACU (Post-Anesthesia Care Unit) on 7/25/12 at 8:10 AM. The surveyor observed Employee Identifier (EI) # 3, Registered Nurse (RN) # 1 in PACU remove a pair of gloves, go into supply room, return to the patient's bedside and reglove without preforming hand hygiene.

On 7/25/12 at 8:20 AM the surveyor observed EI # 4, RN # 2 in PACU, remove a pair of gloves, go to treatment area, return and regloved without hand hygiene.

On 7/25/12 at 8:30 AM the surveyor observed EI # 5, the circulating nurse, preparing a surgical suite for surgery. EI # 5 was opening packages and placing them on the sterile field. EI # 5 dropped a supply item on the floor. EI # 5 reached down and picked the item up off the floor and resumed placing items on the sterile field with out hand hygiene.

An interview was conducted on 7/25 12 at 9:00 AM with EI # 6, a Director of Clinical Excellence. The surveyor asked if employees were required to preform hand hygiene between gloves and after picking items off the floor and the response was, "yes".


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2. MR # 4 was admitted on 7/23/12 with diagnoses including Cellulitis Not Otherwise Specified. Review of the medical record document titled Present on Admission Progress Note dated 7/23/12 revealed nursing documentation of " scabbed area x (times) 2 (two) noted RLE (right lower extremity) " .

The surveyor observed wound care on 7/25/12 at 9: 50 AM, performed by EI # 9, Registered Nurse. The surveyor observed the patient had 2 wounds to the right lower extremity (shin area) that contained both granulation tissue and slough. EI # 9 washed his/her hands, retrieved ordered supplies, placed the supplies on the bedside table and donned gloves. EI # 9 cleansed wound # (number) 1 (one) with a gauze saturated with NS (normal saline) and discarded the used gauze. EI # 9 then cleansed wound # 2 with a new gauze saturated with NS. Bactroban ointment was applied to wound 1 and wound 2, using a separate Q-tip.

EI # 9 failed to perform hand hygiene and change his/her gloves between each wound as per facility policy.

Medical record review of nursing assessments flowsheets dated 7/23/12, 7/24/12 and 7/25/12 revealed documentation of only 1 wound to the right lower leg.

An interview was conducted, following the procedure, with EI # 10, RN, Accreditation Regulatory Coordinator, who was present during the care. EI # 10 validated the patient had 2 separate wounds to the right lower leg.