HospitalInspections.org

Based on record review and interview, it was determined the governing body failed to ensure:

1. The Primary Physician followed up in 1 of 1 records reviewed where the patient's albumin level was low and the nutritional consult requested a nutritional supplement.

Refer to A 049

2. The patients were cared for in a safe environment including staff wearing gloves, handwashing and clean equipment.

Refer to A 144

3. The Nursing staff:

A. Provided wound care as ordered

B. Provided an initial assessment of the patients with wounds

C. Provided an ongoing assessment of the patients with wounds.

D. Followed the Facility Policy for wound care.

Refer to A 395

4. The pharmacist followed standards for wound care medication orders.

Refer to A 500

5. All infection control policies and standards were followed by the staff.

Refer to A 748

This had the potential to negatively affect all patients served by the facility and did negatively affect Patient Identifer #s 1, 2 , and 3.

Based on record review and interview, it was determined the governing body failed to ensure the Primary Physician followed up in 1 of 1 records reviewed where the patient's albumin level was low and the nutritional consult requested a nutritional supplement. This negatively affected Patient Identifer (PI) # 1 and had the potential to negatively affect all patients served by this facility.

Findings include:

1. PI # 1 was admitted to the facility on 12/24/12 with diagnoses including Cholecystitis, Possible Common Bile Duct Obstruction, Ileus, Hypertension, and Back Pain.

Review of the laboratory results dated 12/25/12 at 4:48 AM revealed a albumin level of 2.30 (normal 3.5 to 5.00).

Review of the Nutritional Assessment dated 12/26/12 at 3:20 PM revealed recommendations by the Dietician as follows:
Dental Soft diet
Ensure TID (three times a day) as a nutritional supplement
Monitor weights, labs, intake and output
Continue multivitamin and Oscal D BID (twice a day).

Review of the progress notes dated 12/27/12 at 3:20 PM revealed documentation the Nutritional Services had Nutritional recommendations under the Dietary Tab.

Review of the Nutritional Assessment dated 12/31/12 at 2:00 PM revealed the following documentation by the Dietician :
No weight recorded, no D/U (Decubitus Ulcer) per flowsheet
Diet: Dental Soft with < 30% intake
Dietitian's Note recommended the following:
Continue Dental Soft diet
Assist in menu selection, tray set-up. Encourage intake of food and fluids.
Honor all food preferences per diet order.
Add Ensure TID with meals
Monitor weights, labs, intake and output
Add Oscal D BID.

Review of the progress notes dated 12/31/12 at 2:00 PM revealed documentation the Nutritional Services had Nutritional recommendations under the Dietary Tab. There were 14 entries per physicians in the progress notes between 12/27/12 and 12/31/12 Dietary entries.

Review of the Nutritional Assessment dated 1/5/13 at 5:35 PM revealed the following documentation by the Dietician :
No weight recorded, no D/U per flowsheet
Diet: Dental Soft with very poor intake reported by patient and no intake recorded. Patient request soup with lunch and dinner trays...
Dietitian's Note recommended the following:
Continue Dental Soft diet encourage intake
Assist in menu selection in AM, help with tray set-up. Encourage intake of food and fluids.
Honor all food preferences.
Add Ensure TID with meals
Monitor weights, labs, intake and output
Oscal D BID.

Review of the progress notes dated 1/5/13 at 5:35 PM revealed documentation the Nutritional Services had Nutritional recommendations under the Dietary Tab. There were 15 entries in the progress notes per physicians between 12/31/12 and 1/5/13 Dietary entries.

Review of the Nutritional Assessment dated 1/10/13 at 4:10 PM revealed the following documentation by the Dietician :
No weight recorded, no D/U per flowsheet
Diet: Mechanical Soft
Dietitian's Note recommended the following:
Continue diet encourage intake.
Patient may benefit from appetite stimulant
Check Prealbumin
Continue multivitamin
Monitor weights, labs, intake and output.

Review of the Vital Signs/I (intake) and O (output) Record between 12/24/12 and 1/14/13 revealed no documentation of the amount of meal consumption by the patient.

Review of the Physician Orders and Medication Administration Record revealed the following:

1. No documentation the physician ordered a dietary supplement three times a day with meals.

2. No documentation the physician ordered a weight check.

3. No documentation of an Albumin assessment after 12/25/12.

4. No documentation of an appetite stimulant until 1/13/13.

5. No documentation of an order to monitor the patient's meal consumption.

An interview was conducted with Employee Identifier (EI) # 1, Primary Physician on 1/16/13 at 7:40 AM. The surveyor asked EI # 1 if he/she was aware the Dietician made three different recommendations for Ensure 3 times a day and was there a reason the Ensure was not ordered? EI # 1 stated he/she was not aware of the ensure recommendation.

Review of PI # 1's medical record on 1/16/13 at 8:00 AM revealed an order from EI # 1 at 7:50 AM for Ensure or Boost three times a day.

The governing body failed to ensure the Primary Physician reviewed all recommendations made by the Nutritional Consultant.

Based on observations and interviews it was determined the facility failed to ensure the patients were cared for in a safe environment including staff wearing gloves, handwashing and clean equipment. This affected Patient Identifer (PI) # 3 and had the potential to negatively affect all patients served by this facility.

Findings include:

A tour of the Emergency Department (ED) was conducted on 1/16/13 at 1:30 PM. The surveyor reviewed the ED logs for 2013 and requested 10 medical records to be reviewed by the surveyor.

During observation of care provided on 1/16/13 from 1:30 PM to 3:00 PM the surveyor observed the following:

1. Employee Identifier (EI) # 8, ED Nurse was observed placing linen in the dirty linen container with an ungloved hand. EI # 8 then went back to the patient care area without hand hygiene.

2. EI # 8 then left the patient care area without hand hygiene and began documenting in the computer.

3. EI # 8 was observed obtaining blood via left antecubital space with a butterfly needle without gloves.

4. A step stool was observed in ED room # 101 with a reddish ring stain approximately 6 cm (centimeter) in diameter.

An interview was conducted with EI # 7, ED Director on 1/16/13 at 2:45 PM. EI # 7 stated recognition of 1 of 10 ED records requested by the surveyor. The surveyor asked which patient it was and the response was PI # 3. The surveyor then asked why he/she recognized PI # 3. EI # 7 stated that the Charge Nurse called on 1/7/13 to inform EI # 7 of a incidence with PI # 3. EI # 7 stated that PI # 3 sat on the stretcher and a few minutes later realized her cloths were wet from the previous patients urine. EI # 7 stated that the mattress was not cleaned underneath and the urine was from the previous patient.

Based on review of medical records, facility policies and procedures, and drug interaction standards and interviews with administrative staff, it was determined the nursing staff failed to:

1. Provide wound care as ordered

2. Provide an initial assessment of the patients with wounds

3. Provide an ongoing assessment of the patients with wounds.

4. Follow the Facility Policy for wound care.

5. Follow Drug Interaction Standards for wound care.

This affected 2 of 2 records reviewed with wounds Patient Identifer # 1 and 2 and had the potential to negatively affect all patients with wounds.

Refer to A 395

Based on review of medical records, facility policies and procedures, and drug interaction standards and interviews with administrative staff, it was determined the nursing staff failed to:

1. Provide wound care as ordered

2. Provide an initial assessment of the patients with wounds

3. Provide an ongoing assessment of the patients with wounds.

4. Follow the Facility Policy for wound care.

5. Follow Drug Interaction Standards for wound care.

This affected 2 of 2 records reviewed with wounds (Patient Identifer (PI) # 1 and 2) and had the potential to negatively affect all patients with wounds.

Findings include:

Facility Policy: Assessment and Reassessment of Patients by Nursing Staff issued 4/5/10

1. Purpose: To establish guidelines for the admission assessment and reassessment of patients by the nursing staff to Medical West.

3. Standards:

3.1.2 The Admission Assessment is the responsibility of the registered nurse. The registered nurse will assess the patient upon admission.

3.1.4 The assessment data will be utilized in the development of the individualized nursing care plan.

3.1.5 The assessment may be accomplished through interview and observation of the patient, family and/or significant other and through review of other pertinent data such as; history and physical, x-ray reports, laboratory reports, previous admissions records and physician notes.

3.1.6 The admission assessment will include factors influencing nursing care or discharge planning, such as, a significant past medical history, age related factors, social history, presence or absence of pain, personal factors and a systems assessment.

4. PROCEDURE/CRITERION CHECKLIST:

Procedure Steps/Critical Elements: Admission assessment

1. COMPLETE ADMISSION ASSESSMENT AND HEALTH HISTORY...

Complete Skin Assessment

************

Braden Scale Protocol Interventions

Risk Factor 16 and below, Skin is broken HIGH RISK INTERVENTIONS

17. Order Wound Consult

18. All care should start ON admission. MEASURE ALL wounds, take photo and (place) in progress notes

************

Information from Drugs.com

Drug interactions between Grafco Silver Nitrate (Silvadene) and Santyl

Generally Avoid: The enzymatic activity of collagenase (santyl) may be adversely affected by heavy metal ions such as mercury and silver, which are found in some antiseptics. The mechanism of interaction has not been described.

Management: Topical preparations containing heavy metals such as silver and mercury should not be used on wounds treated with collagenase. When it is suspected such products have been used, the site should be carefully cleansed by repeated washings with normal saline before application of collagenase.

************

Facility Policy: Dressing Change Issued 4/5/10

1. Purpose: To establish guidelines for wound dressing changes.

2. Philosophy: It is our belief that proper wound dressing changes minimize the potential for infection and promote patient comfort and wound healing.

3. Standards:

3.5. Universal Precautions shall be followed during dressing change.

4. Procedure:

4.6. When doing multiple wound dressing changes, follow procedures and do each dressing change separately to prevent cross contamination.

4.7. Wash Hands

4.8. Put on non-sterile gloves.

4.10. Remove soiled dressing and place in plastic bag.

4.11. Remove soiled gloves.

4.12. Wash hands.

4.14. Apply gloves.

************

Facility Policy: Infection Control

OSHA (Occupational Safety and Health Administration) Bloodborne Pathogen Standard

Exposure Control Plan dated 7/30/08

Standard Precautions

1. Healthcare Personnel Hand-Washing

4. Decontaminate hands in the following situations:

h. After removing gloves...

III. Gloves:

B. Gloves must be worn:

1. When there is likelihood of hand contact with blood and any secretions or other potentially infectious materials.

2. During all vascular access procedures.


1. PI # 1 was admitted to the facility on 12/24/12 with admitting diagnoses including Cholecystitis, Possible Common Bile Duct Obstruction, Ileus, Hypertension, and Back Pain.

Review of the Present on Admission Assessment from the Emergency Department dated 12/24/12 at 1:00 PM revealed documentation of a pressure ulcer to the right and left heel. There was no documentation of a measurement, description or photo.

Review of the RN (Registered Nurse) Physical Assessment and History Data dated 12/24/12 at 3:16 PM revealed the following documentation:

No edema, rash, bruises/hematoma, abrasions, lacerations, or fungus

Other Skin Ulcers/lesions (not due to pressure) N (no)

Pressure Ulcer Present on Admission N

Does patient have an open draining wound N

Review of the Plan for Nursing Care: Medical/Surgical Patient revealed no documentation for a goal or intervention under alteration in Healing related to wounds.

Review of the twenty one 24 Hour Flow Sheets dated between 12/24/12 and 1/13/13 revealed no documentation of a dressing change/location, drainage amount & color, or wound appearance for the wounds to the left and right heel.

There was no documentation in the medical record of the patient's pressure ulcers to the left or right heel until 1/12/13 at 12 noon when the daughter asked about the condition of the patient's left heel due to complaints of pain.

Review of the Physician's Order dated 1/12/13 at 5:10 PM revealed an order for General Surgery Consult concerning left foot pain (area on heel).

Review of the Physician's Order dated 1/13/13 at 6:50 AM revealed orders for an I & D (incision and drain) of left heel, removal of the left great toe nail and an I&D 2nd toe nail to be completed 1/14/13.

Review of the Consultation Report dated 1/13/13 revealed patient had been complaining the left heel was sore and found to have a left heel decubitus.

Review of the Operative Note dated 1/15/13 ( which should have been dated 1/14/13) revealed documentation as follows, "...we debrided the heel all the way down to the bone and bleeding tissue...It was a eschar with some wet and dry gangrene noted. We excised it all the way down to the bone...then the second toe on the right foot had what looked like an infection area over the top of the toe. I was able to debride it all the way down to the bleeding tissue..."

Review of the Nurse Note dated 1/14/13 revealed the patient was off the floor to surgery at 9:00 AM and returned to the floor at 4:00 PM.

Review of the Nurse Notes dated 1/15/13 at 9:00 AM revealed the nurse changed the dressing to the left heel.

The medical record was reviewed by the surveyor on 1/15/13 at 10:00 AM. There was no documentation of a decubitus to the left heel until 1/12/13 when the patient began complaining of pain to the left heel. There was no documentation of the left heel wound size, appearance or condition of the surrounding tissue.

In an interview with Employee Identifier ( EI) # 2, Chief Nursing Officer on 1/15/13 at 10:40 AM, when the surveyor asked for wound measurements, photo, and description. EI # 2 was unable to locate any documentation of the wound description of any kind. EI # 2 stated there should have been photos on admission, measurements, descriptions of the wound and surrounding tissue.

On 1/16/13 at 7:50 AM the surveyor reviewed the medical record and there was no documentation of wound measurements, a photo, or a description.

The surveyor then requested to see the wound. EI # 2, Chief Nursing Officer and EI # 3 , Registered Nurse went to PI # 1 room with gauze and normal saline (NS). EI # 2 removed the dressing from the left heel. There was approximately a 5 cm (centimeter) ring of dried blood on the old dressing. EI # 2 threw the dressing in the regular trash. EI # 2 measured the wound 5 cm long, 4 cm wide, and 1/2 cm deep with blood red tissue. Bone was exposed.

EI # 2 cleansed the wound to the left heel with the same pair of gloves used to remove the old dressing, using NS and gauze. EI # 2 then covered the wound with gauze moistened with NS, removed the gloves and EI # 3 then wrapped the wound. EI # 3 then removed the dressing from the left great toe and was waiting for EI # 3 to return with more gauze. The left great toe was dripping blood on to the linen. EI # 3 placed gauze under the toe to catch the dripping blood. After EI # 3 dressed the left great toe EI # 3 threw the gauze the toe had been dripping on in the regular trash.

EI # 3 then removed the dressing from the right 2nd toe with the same pair of gloves used to remove the dressing from the left greater toe. EI # 3 then dressed the left greater toe and the right 2nd toe with the same gloves.

An interview was conducted with EI # 2 on 1/15/13 at 11:00 AM. The surveyor asked if the PI # 1 received a consult with a wound nurse. EI # 2 stated they did not have a wound nurse at present but did use a Nurse Manager as a resource if needed. The surveyor asked if the resource person had seen PI # 1 and the response was no.

2. PI # 2 was admitted to the facility on 12/26/12 with diagnoses including Cancer of the Lung and Wounds to Bilateral Feet.

Review of the Physician's order dated 12/26/12 at 9:00 AM revealed orders for the nurse to remove dressings on lower extremities (LE) and assess and wash the wounds. Wash the lower extremities daily apply Bactroban cream, nonocclusive dressing and wrap.

Review of the Medication Administration Record (MAR) and the Nurse Note dated 12/26/12 revealed no documentation the nurse washed the LE, applied Bactroban cream, nonocclusive dressing and wrapped.

Review of the Physician's Order dated 12/28/12 at 7:15 AM revealed orders for the staff to treat both foot wounds daily with Santyl - apply a layer "nickle - thick" and wet to dry dressing on top of both - then wrap feet with kerlix.

Review of the physician's order dated 12/29/12 at 4:45 PM revealed orders for silvadene dressings to both foot wounds now and daily.

Review of the MAR and the Nurse Note dated 12/29/12 revealed no documentation the staff applied silvadene to both wounds on the feet.

Review of the MARs dated 12/30/12, 12/31/12, 1/1/13, and 1/2/13 revealed documentation the nurses applied both santyl and silvadene.

Review of the physician's order dated 1/3/13 at 1:00 PM revealed orders for the following dressing changes. Apply Santyl to both foot wounds daily with wet to dry dressings and Kerlix wrap.

Review of the MARs dated 1/3/13, 1/4/13, 1/5/13, 1/6/13, 1/7/13, 1/8/13, 1/9/13, 1/10/13, 1/11/12, 1/12/13, 1/13/13, 1/14/13, and 1/15/13 revealed documentation the nurses applied both santyl and silvadene.

An interview was conducted with EI # 4, Pharmacist on 1/13/13 at 11:35 AM. The surveyor asked why the staff continued to apply Santyl and Silvadene, did one not counter act the other. The response was the pharmacy staff were not told to stop one wound care to begin another.

An interview was conducted with EI # 6, Surgeon on 1/16/13 at 12:30 PM. The surveyor asked if EI # 6 expected the staff to stop using one wound care order before starting another. EI # 6 stated, "Yes I would. They did didn't they?" The surveyor told EI # 6 that the staff were using both Santyl and Silvadene at the same time. EI # 6 stated, "Oh no."

Based on record review, review of drug interaction standards, and interviews, it was determined the facility failed to ensure the pharmacist followed standards for wound care in 1 of 2 wound care records reviewed. This affected Patient Identifier # 2 and had the potential to negatively affect all patients served by this facility who had wound care.

Findings include:

Information from Drugs.com

Drug interactions between Grafco Silver Nitrate (Silvadene) and Santyl

Generally Avoid: The enzymatic activity of collagenase (santyl) may be adversely affected by heavy metal ions such as mercury and silver, which are found in some antiseptics. The mechanism of interaction has not been described.

Management: Topical preparations containing heavy metals such as silver and mercury should not be used on wounds treated with collagenase. When it is suspected such products have been used, the site should be carefully cleansed by repeated washings with normal saline before application of collagenase.


1. PI # 2 was admitted to the facility on 12/26/12 with diagnoses including Cancer of the Lung and Wounds to Bilateral Feet.

Review of the Physician's order dated 12/26/12 at 9:00 AM revealed orders for the nurse to remove dressings on lower extremities (LE) and assess and wash the wounds. Wash the lower extremities daily apply Bactroban cream, nonocclusive dressing and wrap.

Review of the Medication Administration Record (MAR) and the Nurse Note dated 12/26/12 revealed no documentation the nurse washed the LE, applied Bactroban cream, nonocclusive dressing and wrapped.

Review of the Physician's Order dated 12/28/12 at 7:15 AM revealed orders for the staff to treat both foot wounds daily with Santyl - apply a layer "nickle - thick" and wet to dry dressing on top of both - then wrap feet with kerlix.

Review of the physician's order dated 12/29/12 at 4:45 PM revealed orders for silvadene dressings to both foot wounds now and daily.

Review of the MAR and the Nurse Note dated 12/29/12 revealed no documentation the staff applied silvadene to both wounds on the feet.

Review of the MARs dated 12/30/12, 12/31/12, 1/1/13, and 1/2/13 revealed documentation the nurses applied both santyl and silvadene.

Review of the physician's order dated 1/3/13 at 1:00 PM revealed orders for dressing changes apply Santyl to both foot wounds daily with wet to dry dressings and Kerlix wrap.

Review of the MARs dated 1/3/13, 1/4/13, 1/5/13, 1/6/13, 1/7/13, 1/8/13, 1/9/13, 1/10/13, 1/11/12, 1/12/13, 1/13/13, 1/14/13, and 1/15/13 revealed documentation the nurses applied both santyl and silvadene.

An interview was conducted with EI # 4, Pharmacist on 1/13/13 at 11:35 AM. The surveyor asked why the staff continued to apply Santyl and Silvadene, did one not counter act the other. The response was the pharmacy staff were not told to stop one wound care to begin another.

An interview was conducted with EI # 6, Surgeon on 1/16/13 at 12:30 PM. The surveyor asked if EI # 6 expected the staff to stop using one wound care order before starting another. EI # 6 stated, "Yes I would. They did didn't they?" The surveyor told EI # 6 that the staff were using both Santyl and Silvadene at the same time. EI # 6 stated, "Oh no."

The pharmacist submitted documentation to the surveyor on 1/16/13 at 3:30 PM which stated, " A search on the Internet sources revealed some information related to a possible interaction where the debriding activity of Santyl could be reduced in combination with Silvadene..."

Based on observations and interviews it was determined the infection control officer failed to ensure all infection control policies and standards were followed by the staff. This affected Patient Identifer # 1 and 3 and had the potential to negatively affect all patients served by this facility.

Refer to A 748

Based on observations and interviews it was determined the infection control officer failed to ensure all infection control policies and standards were followed by the staff. This affected Patient Identifer # 1 and 3 and had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: Dressing Change Issued 4/5/10

1. Purpose: To establish guidelines for wound dressing changes.

2. Philosophy: It is our belief that proper wound dressing changes minimize the potential for infection and promote patient comfort and wound healing.

3. Standards:

3.5. Universal Precautions shall be followed during dressing change.

4. Procedure:

4.6. When doing multiple wound dressing changes, follow procedures and do each dressing change separately to prevent cross contamination.

4.7. Wash Hands

4.8. Put on non-sterile gloves.

4.10. Remove soiled dressing and place in plastic bag.

4.11. Remove soiled gloves.

4.12. Wash hands.

4.14. Apply gloves.

************

Centers for Disease Control (CDC) Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings

What Type of PPE Would You Wear?

Drawing blood from a vein? Gloves

************

Facility Policy: Infection Control

OSHA (Occupational Safety and Health Administration) Bloodborne Pathogen Standard

Exposure Control Plan dated 7/30/08

Standard Precautions

1. Healthcare Personnel Hand-Washing

4. Decontaminate hands in the following situations:

h. After removing gloves...

III. Gloves:

B. Gloves must be worn:

1. When there is likelihood of hand contact with blood and any secretions or other potentially infectious materials.

2. During all vascular access procedures.



A tour of the Emergency Department (ED) was conducted on 1/16/13 at 1:30 PM. The surveyor reviewed the ED logs for 2013 and requested 10 medical records to review.

During observation of care provided on 1/16/13 from 1:30 PM to 3:00 PM the surveyor observed the following:

1. Employee Identifier (EI) # 8, ED Nurse was observed placing linen in the dirty linen container with a gloved hand. EI # 8 then went back to the patient care area without hand hygiene.

2. EI # 8 then left the patient care area without hand hygiene and began documenting in the computer.

3. EI # 8 was observed obtaining blood via left antecubital space with a butterfly needle without gloves.

4. A step stool was observed in ED room # 101 with a red blood appearance stain.

5. Several room were observed being cleaned between patients. When the stretcher in each room was cleaned the staff did not clean under the mattress.

6. During observation of ED room 101 being cleaned between patients, a staff member was observed placing a urinal with approximately 200 cc (cubic centimeters) of urine in the regular trash.

An interview was conducted with EI # 7, ED Director on 1/16/13 at 2:45 PM. EI # 7 stated recognition of 1 of 10 ED records pulled by the surveyor. The surveyor asked which patient it was and the response was PI # 3. The surveyor then asked why he/she recognized PI # 3. EI # 7 stated that the Charge Nurse called him on 1/7/13 to inform EI # 7 of a incidence with PI # 3. EI # 7 stated that PI # 3 sat on the stretcher and a few minutes later realized her clothes were wet from the previous patient's urine. EI # 7 stated that the mattress was not cleaned underneath and the urine from the previous patient was left.

Facility Policy: Dressing Change Issued 4/5/10

1. Purpose: To establish guidelines for wound dressing changes.

2. Philosophy: It is our belief that proper wound dressing changes minimize the potential for infection and promote patient comfort and wound healing.

3. Standards:

3.5. Universal Precautions shall be followed during dressing change.

4. Procedure:

4.6. When doing multiple wound dressing changes, follow procedures and do each dressing change separately to prevent cross contamination.

4.7. Wash Hands

4.8. Put on non-sterile gloves.

4.10. Remove soiled dressing and place in plastic bag.

4.11. Remove soiled gloves.

4.12. Wash hands.

4.14. Apply gloves.

************

CDC Guidelines for Bloodborne Pathogens
by Beth Celli, eHow Contributor

Bloodborne Pathogens

Bloodborne pathogens are microscopic organisms (or microorganisms) that can cause illness in people. They are found in the blood or other body fluids. Human immunodeficiency virus (HIV) which causes AIDS, and hepatitis B virus (HBV), are two of the most common bloodborne pathogens. These diseases and others pose a serious threat to health care workers.

Management of Waste

All materials that are contaminated with blood or body fluids should be disposed of in a red bag, or biohazard trash...


1. PI # 1 was admitted to the facility on 12/24/12 with admitting diagnoses including Cholecystitis, Possible Common Bile Duct Obstruction, Ileus, Hypertension, and Back Pain.


Review of the Operative Note dated 1/15/13 ( which should have been 1/14/13) revealed documentation as follows, "...we debrided the heel all the way down to the bone and bleeding tissue...It was a eschar with some wet and dry gangrene noted. We excised it all the way down to the bone...then the second toe on the right foot had what looked like an infection area over the top of the toe. I was able to debride it all the way down to the bleeding tissue..."

An interview with Employee Identifier ( EI) # 2, Chief Nursing Officer on 1/15/13/at 10:40 AM when the surveyor asked for wound measurements, photo, and description. EI # 2 was unable to locate any documentation of the wound description of any kind. EI # 2 stated there should have been photos on admission, measurements, descriptions of the wound and surrounding tissue.

On 1/16/13 at 7:50 AM the surveyor reviewed the medical record and there was no documentation of wound measurements, a photo, or a description.

The surveyor then requested to see the wound. EI # 2 and EI # 3 , Registered Nurse went to PI # 1's room with gauze and normal saline (NS). EI # 2 removed the dressing from the left heel. There was approximately a 5 cm (centimeter) ring of dried blood on the old dressing. EI # 2 threw the dressing in the regular trash. EI # 2 measured the wound 5 cm long, 4 cm wide, and 1/2 cm deep with blood red tissue. Bone was exposed.

EI # 2 cleansed the wound to the left heel and then covered the wound with gauze moistened with NS with the same pair of gloves used to remove the old dressing. EI # 3 then wrapped the wound to the left heel. EI # 3 then removed the dressing from the left great toe and was waiting for EI # 3 to return with more gauze. The left great toe was dripping blood on to the linen. EI # 3 then placed gauze under the toe to catch the dripping blood. After EI # 3 dressed the left great toe EI # 3 threw the gauze the toe had been dripping on in the regular trash.

EI # 3 then removed the dressing from the right 2nd toe with the same pair of gloves used to remove the dressing from the left great toe. EI # 3 then dressed the left great toe and the right 2nd toe using the same gloves.

Based on record review and interview, it was determined the governing body failed to ensure:

1. The Primary Physician followed up in 1 of 1 records reviewed where the patient's albumin level was low and the nutritional consult requested a nutritional supplement.

Refer to A 049

2. The patients were cared for in a safe environment including staff wearing gloves, handwashing and clean equipment.

Refer to A 144

3. The Nursing staff:

A. Provided wound care as ordered

B. Provided an initial assessment of the patients with wounds

C. Provided an ongoing assessment of the patients with wounds.

D. Followed the Facility Policy for wound care.

Refer to A 395

4. The pharmacist followed standards for wound care medication orders.

Refer to A 500

5. All infection control policies and standards were followed by the staff.

Refer to A 748

This had the potential to negatively affect all patients served by the facility and did negatively affect Patient Identifer #s 1, 2 , and 3.

Based on record review and interview, it was determined the governing body failed to ensure the Primary Physician followed up in 1 of 1 records reviewed where the patient's albumin level was low and the nutritional consult requested a nutritional supplement. This negatively affected Patient Identifer (PI) # 1 and had the potential to negatively affect all patients served by this facility.

Findings include:

1. PI # 1 was admitted to the facility on 12/24/12 with diagnoses including Cholecystitis, Possible Common Bile Duct Obstruction, Ileus, Hypertension, and Back Pain.

Review of the laboratory results dated 12/25/12 at 4:48 AM revealed a albumin level of 2.30 (normal 3.5 to 5.00).

Review of the Nutritional Assessment dated 12/26/12 at 3:20 PM revealed recommendations by the Dietician as follows:
Dental Soft diet
Ensure TID (three times a day) as a nutritional supplement
Monitor weights, labs, intake and output
Continue multivitamin and Oscal D BID (twice a day).

Review of the progress notes dated 12/27/12 at 3:20 PM revealed documentation the Nutritional Services had Nutritional recommendations under the Dietary Tab.

Review of the Nutritional Assessment dated 12/31/12 at 2:00 PM revealed the following documentation by the Dietician :
No weight recorded, no D/U (Decubitus Ulcer) per flowsheet
Diet: Dental Soft with < 30% intake
Dietitian's Note recommended the following:
Continue Dental Soft diet
Assist in menu selection, tray set-up. Encourage intake of food and fluids.
Honor all food preferences per diet order.
Add Ensure TID with meals
Monitor weights, labs, intake and output
Add Oscal D BID.

Review of the progress notes dated 12/31/12 at 2:00 PM revealed documentation the Nutritional Services had Nutritional recommendations under the Dietary Tab. There were 14 entries per physicians in the progress notes between 12/27/12 and 12/31/12 Dietary entries.

Review of the Nutritional Assessment dated 1/5/13 at 5:35 PM revealed the following documentation by the Dietician :
No weight recorded, no D/U per flowsheet
Diet: Dental Soft with very poor intake reported by patient and no intake recorded. Patient request soup with lunch and dinner trays...
Dietitian's Note recommended the following:
Continue Dental Soft diet encourage intake
Assist in menu selection in AM, help with tray set-up. Encourage intake of food and fluids.
Honor all food preferences.
Add Ensure TID with meals
Monitor weights, labs, intake and output
Oscal D BID.

Review of the progress notes dated 1/5/13 at 5:35 PM revealed documentation the Nutritional Services had Nutritional recommendations under the Dietary Tab. There were 15 entries in the progress notes per physicians between 12/31/12 and 1/5/13 Dietary entries.

Review of the Nutritional Assessment dated 1/10/13 at 4:10 PM revealed the following documentation by the Dietician :
No weight recorded, no D/U per flowsheet
Diet: Mechanical Soft
Dietitian's Note recommended the following:
Continue diet encourage intake.
Patient may benefit from appetite stimulant
Check Prealbumin
Continue multivitamin
Monitor weights, labs, intake and output.

Review of the Vital Signs/I (intake) and O (output) Record between 12/24/12 and 1/14/13 revealed no documentation of the amount of meal consumption by the patient.

Review of the Physician Orders and Medication Administration Record revealed the following:

1. No documentation the physician ordered a dietary supplement three times a day with meals.

2. No documentation the physician ordered a weight check.

3. No documentation of an Albumin assessment after 12/25/12.

4. No documentation of an appetite stimulant until 1/13/13.

5. No documentation of an order to monitor the patient's meal consumption.

An interview was conducted with Employee Identifier (EI) # 1, Primary Physician on 1/16/13 at 7:40 AM. The surveyor asked EI # 1 if he/she was aware the Dietician made three different recommendations for Ensure 3 times a day and was there a reason the Ensure was not ordered? EI # 1 stated he/she was not aware of the ensure recommendation.

Review of PI # 1's medical record on 1/16/13 at 8:00 AM revealed an order from EI # 1 at 7:50 AM for Ensure or Boost three times a day.

The governing body failed to ensure the Primary Physician reviewed all recommendations made by the Nutritional Consultant.

Based on observations and interviews it was determined the facility failed to ensure the patients were cared for in a safe environment including staff wearing gloves, handwashing and clean equipment. This affected Patient Identifer (PI) # 3 and had the potential to negatively affect all patients served by this facility.

Findings include:

A tour of the Emergency Department (ED) was conducted on 1/16/13 at 1:30 PM. The surveyor reviewed the ED logs for 2013 and requested 10 medical records to be reviewed by the surveyor.

During observation of care provided on 1/16/13 from 1:30 PM to 3:00 PM the surveyor observed the following:

1. Employee Identifier (EI) # 8, ED Nurse was observed placing linen in the dirty linen container with an ungloved hand. EI # 8 then went back to the patient care area without hand hygiene.

2. EI # 8 then left the patient care area without hand hygiene and began documenting in the computer.

3. EI # 8 was observed obtaining blood via left antecubital space with a butterfly needle without gloves.

4. A step stool was observed in ED room # 101 with a reddish ring stain approximately 6 cm (centimeter) in diameter.

An interview was conducted with EI # 7, ED Director on 1/16/13 at 2:45 PM. EI # 7 stated recognition of 1 of 10 ED records requested by the surveyor. The surveyor asked which patient it was and the response was PI # 3. The surveyor then asked why he/she recognized PI # 3. EI # 7 stated that the Charge Nurse called on 1/7/13 to inform EI # 7 of a incidence with PI # 3. EI # 7 stated that PI # 3 sat on the stretcher and a few minutes later realized her cloths were wet from the previous patients urine. EI # 7 stated that the mattress was not cleaned underneath and the urine was from the previous patient.

Based on review of medical records, facility policies and procedures, and drug interaction standards and interviews with administrative staff, it was determined the nursing staff failed to:

1. Provide wound care as ordered

2. Provide an initial assessment of the patients with wounds

3. Provide an ongoing assessment of the patients with wounds.

4. Follow the Facility Policy for wound care.

5. Follow Drug Interaction Standards for wound care.

This affected 2 of 2 records reviewed with wounds Patient Identifer # 1 and 2 and had the potential to negatively affect all patients with wounds.

Refer to A 395

Based on review of medical records, facility policies and procedures, and drug interaction standards and interviews with administrative staff, it was determined the nursing staff failed to:

1. Provide wound care as ordered

2. Provide an initial assessment of the patients with wounds

3. Provide an ongoing assessment of the patients with wounds.

4. Follow the Facility Policy for wound care.

5. Follow Drug Interaction Standards for wound care.

This affected 2 of 2 records reviewed with wounds (Patient Identifer (PI) # 1 and 2) and had the potential to negatively affect all patients with wounds.

Findings include:

Facility Policy: Assessment and Reassessment of Patients by Nursing Staff issued 4/5/10

1. Purpose: To establish guidelines for the admission assessment and reassessment of patients by the nursing staff to Medical West.

3. Standards:

3.1.2 The Admission Assessment is the responsibility of the registered nurse. The registered nurse will assess the patient upon admission.

3.1.4 The assessment data will be utilized in the development of the individualized nursing care plan.

3.1.5 The assessment may be accomplished through interview and observation of the patient, family and/or significant other and through review of other pertinent data such as; history and physical, x-ray reports, laboratory reports, previous admissions records and physician notes.

3.1.6 The admission assessment will include factors influencing nursing care or discharge planning, such as, a significant past medical history, age related factors, social history, presence or absence of pain, personal factors and a systems assessment.

4. PROCEDURE/CRITERION CHECKLIST:

Procedure Steps/Critical Elements: Admission assessment

1. COMPLETE ADMISSION ASSESSMENT AND HEALTH HISTORY...

Complete Skin Assessment

************

Braden Scale Protocol Interventions

Risk Factor 16 and below, Skin is broken HIGH RISK INTERVENTIONS

17. Order Wound Consult

18. All care should start ON admission. MEASURE ALL wounds, take photo and (place) in progress notes

************

Information from Drugs.com

Drug interactions between Grafco Silver Nitrate (Silvadene) and Santyl

Generally Avoid: The enzymatic activity of collagenase (santyl) may be adversely affected by heavy metal ions such as mercury and silver, which are found in some antiseptics. The mechanism of interaction has not been described.

Management: Topical preparations containing heavy metals such as silver and mercury should not be used on wounds treated with collagenase. When it is suspected such products have been used, the site should be carefully cleansed by repeated washings with normal saline before application of collagenase.

************

Facility Policy: Dressing Change Issued 4/5/10

1. Purpose: To establish guidelines for wound dressing changes.

2. Philosophy: It is our belief that proper wound dressing changes minimize the potential for infection and promote patient comfort and wound healing.

3. Standards:

3.5. Universal Precautions shall be followed during dressing change.

4. Procedure:

4.6. When doing multiple wound dressing changes, follow procedures and do each dressing change separately to prevent cross contamination.

4.7. Wash Hands

4.8. Put on non-sterile gloves.

4.10. Remove soiled dressing and place in plastic bag.

4.11. Remove soiled gloves.

4.12. Wash hands.

4.14. Apply gloves.

************

Facility Policy: Infection Control

OSHA (Occupational Safety and Health Administration) Bloodborne Pathogen Standard

Exposure Control Plan dated 7/30/08

Standard Precautions

1. Healthcare Personnel Hand-Washing

4. Decontaminate hands in the following situations:

h. After removing gloves...

III. Gloves:

B. Gloves must be worn:

1. When there is likelihood of hand contact with blood and any secretions or other potentially infectious materials.

2. During all vascular access procedures.


1. PI # 1 was admitted to the facility on 12/24/12 with admitting diagnoses including Cholecystitis, Possible Common Bile Duct Obstruction, Ileus, Hypertension, and Back Pain.

Review of the Present on Admission Assessment from the Emergency Department dated 12/24/12 at 1:00 PM revealed documentation of a pressure ulcer to the right and left heel. There was no documentation of a measurement, description or photo.

Review of the RN (Registered Nurse) Physical Assessment and History Data dated 12/24/12 at 3:16 PM revealed the following documentation:

No edema, rash, bruises/hematoma, abrasions, lacerations, or fungus

Other Skin Ulcers/lesions (not due to pressure) N (no)

Pressure Ulcer Present on Admission N

Does patient have an open draining wound N

Review of the Plan for Nursing Care: Medical/Surgical Patient revealed no documentation for a goal or intervention under alteration in Healing related to wounds.

Review of the twenty one 24 Hour Flow Sheets dated between 12/24/12 and 1/13/13 revealed no documentation of a dressing change/location, drainage amount & color, or wound appearance for the wounds to the left and right heel.

There was no documentation in the medical record of the patient's pressure ulcers to the left or right heel until 1/12/13 at 12 noon when the daughter asked about the condition of the patient's left heel due to complaints of pain.

Review of the Physician's Order dated 1/12/13 at 5:10 PM revealed an order for General Surgery Consult concerning left foot pain (area on heel).

Review of the Physician's Order dated 1/13/13 at 6:50 AM revealed orders for an I & D (incision and drain) of left heel, removal of the left great toe nail and an I&D 2nd toe nail to be completed 1/14/13.

Review of the Consultation Report dated 1/13/13 revealed patient had been complaining the left heel was sore and found to have a left heel decubitus.

Review of the Operative Note dated 1/15/13 ( which should have been dated 1/14/13) revealed documentation as follows, "...we debrided the heel all the way down to the bone and bleeding tissue...It was a eschar with some wet and dry gangrene noted. We excised it all the way down to the bone...then the second toe on the right foot had what looked like an infection area over the top of the toe. I was able to debride it all the way down to the bleeding tissue..."

Review of the Nurse Note dated 1/14/13 revealed the patient was off the floor to surgery at 9:00 AM and returned to the floor at 4:00 PM.

Review of the Nurse Notes dated 1/15/13 at 9:00 AM revealed the nurse changed the dressing to the left heel.

The medical record was reviewed by the surveyor on 1/15/13 at 10:00 AM. There was no documentation of a decubitus to the left heel until 1/12/13 when the patient began complaining of pain to the left heel. There was no documentation of the left heel wound size, appearance or condition of the surrounding tissue.

In an interview with Employee Identifier ( EI) # 2, Chief Nursing Officer on 1/15/13 at 10:40 AM, when the surveyor asked for wound measurements, photo, and description. EI # 2 was unable to locate any documentation of the wound description of any kind. EI # 2 stated there should have been photos on admission, measurements, descriptions of the wound and surrounding tissue.

On 1/16/13 at 7:50 AM the surveyor reviewed the medical record and there was no documentation of wound measurements, a photo, or a description.

The surveyor then requested to see the wound. EI # 2, Chief Nursing Officer and EI # 3 , Registered Nurse went to PI # 1 room with gauze and normal saline (NS). EI # 2 removed the dressing from the left heel. There was approximately a 5 cm (centimeter) ring of dried blood on the old dressing. EI # 2 threw the dressing in the regular trash. EI # 2 measured the wound 5 cm long, 4 cm wide, and 1/2 cm deep with blood red tissue. Bone was exposed.

EI # 2 cleansed the wound to the left heel with the same pair of gloves used to remove the old dressing, using NS and gauze. EI # 2 then covered the wound with gauze moistened with NS, removed the gloves and EI # 3 then wrapped the wound. EI # 3 then removed the dressing from the left great toe and was waiting for EI # 3 to return with more gauze. The left great toe was dripping blood on to the linen. EI # 3 placed gauze under the toe to catch the dripping blood. After EI # 3 dressed the left great toe EI # 3 threw the gauze the toe had been dripping on in the regular trash.

EI # 3 then removed the dressing from the right 2nd toe with the same pair of gloves used to remove the dressing from the left greater toe. EI # 3 then dressed the left greater toe and the right 2nd toe with the same gloves.

An interview was conducted with EI # 2 on 1/15/13 at 11:00 AM. The surveyor asked if the PI # 1 received a consult with a wound nurse. EI # 2 stated they did not have a wound nurse at present but did use a Nurse Manager as a resource if needed. The surveyor asked if the resource person had seen PI # 1 and the response was no.

2. PI # 2 was admitted to the facility on 12/26/12 with diagnoses including Cancer of the Lung and Wounds to Bilateral Feet.

Review of the Physician's order dated 12/26/12 at 9:00 AM revealed orders for the nurse to remove dressings on lower extremities (LE) and assess and wash the wounds. Wash the lower extremities daily apply Bactroban cream, nonocclusive dressing and wrap.

Review of the Medication Administration Record (MAR) and the Nurse Note dated 12/26/12 revealed no documentation the nurse washed the LE, applied Bactroban cream, nonocclusive dressing and wrapped.

Review of the Physician's Order dated 12/28/12 at 7:15 AM revealed orders for the staff to treat both foot wounds daily with Santyl - apply a layer "nickle - thick" and wet to dry dressing on top of both - then wrap feet with kerlix.

Review of the physician's order dated 12/29/12 at 4:45 PM revealed orders for silvadene dressings to both foot wounds now and daily.

Review of the MAR and the Nurse Note dated 12/29/12 revealed no documentation the staff applied silvadene to both wounds on the feet.

Review of the MARs dated 12/30/12, 12/31/12, 1/1/13, and 1/2/13 revealed documentation the nurses applied both santyl and silvadene.

Review of the physician's order dated 1/3/13 at 1:00 PM revealed orders for the following dressing changes. Apply Santyl to both foot wounds daily with wet to dry dressings and Kerlix wrap.

Review of the MARs dated 1/3/13, 1/4/13, 1/5/13, 1/6/13, 1/7/13, 1/8/13, 1/9/13, 1/10/13, 1/11/12, 1/12/13, 1/13/13, 1/14/13, and 1/15/13 revealed documentation the nurses applied both santyl and silvadene.

An interview was conducted with EI # 4, Pharmacist on 1/13/13 at 11:35 AM. The surveyor asked why the staff continued to apply Santyl and Silvadene, did one not counter act the other. The response was the pharmacy staff were not told to stop one wound care to begin another.

An interview was conducted with EI # 6, Surgeon on 1/16/13 at 12:30 PM. The surveyor asked if EI # 6 expected the staff to stop using one wound care order before starting another. EI # 6 stated, "Yes I would. They did didn't they?" The surveyor told EI # 6 that the staff were using both Santyl and Silvadene at the same time. EI # 6 stated, "Oh no."

Based on record review, review of drug interaction standards, and interviews, it was determined the facility failed to ensure the pharmacist followed standards for wound care in 1 of 2 wound care records reviewed. This affected Patient Identifier # 2 and had the potential to negatively affect all patients served by this facility who had wound care.

Findings include:

Information from Drugs.com

Drug interactions between Grafco Silver Nitrate (Silvadene) and Santyl

Generally Avoid: The enzymatic activity of collagenase (santyl) may be adversely affected by heavy metal ions such as mercury and silver, which are found in some antiseptics. The mechanism of interaction has not been described.

Management: Topical preparations containing heavy metals such as silver and mercury should not be used on wounds treated with collagenase. When it is suspected such products have been used, the site should be carefully cleansed by repeated washings with normal saline before application of collagenase.


1. PI # 2 was admitted to the facility on 12/26/12 with diagnoses including Cancer of the Lung and Wounds to Bilateral Feet.

Review of the Physician's order dated 12/26/12 at 9:00 AM revealed orders for the nurse to remove dressings on lower extremities (LE) and assess and wash the wounds. Wash the lower extremities daily apply Bactroban cream, nonocclusive dressing and wrap.

Review of the Medication Administration Record (MAR) and the Nurse Note dated 12/26/12 revealed no documentation the nurse washed the LE, applied Bactroban cream, nonocclusive dressing and wrapped.

Review of the Physician's Order dated 12/28/12 at 7:15 AM revealed orders for the staff to treat both foot wounds daily with Santyl - apply a layer "nickle - thick" and wet to dry dressing on top of both - then wrap feet with kerlix.

Review of the physician's order dated 12/29/12 at 4:45 PM revealed orders for silvadene dressings to both foot wounds now and daily.

Review of the MAR and the Nurse Note dated 12/29/12 revealed no documentation the staff applied silvadene to both wounds on the feet.

Review of the MARs dated 12/30/12, 12/31/12, 1/1/13, and 1/2/13 revealed documentation the nurses applied both santyl and silvadene.

Review of the physician's order dated 1/3/13 at 1:00 PM revealed orders for dressing changes apply Santyl to both foot wounds daily with wet to dry dressings and Kerlix wrap.

Review of the MARs dated 1/3/13, 1/4/13, 1/5/13, 1/6/13, 1/7/13, 1/8/13, 1/9/13, 1/10/13, 1/11/12, 1/12/13, 1/13/13, 1/14/13, and 1/15/13 revealed documentation the nurses applied both santyl and silvadene.

An interview was conducted with EI # 4, Pharmacist on 1/13/13 at 11:35 AM. The surveyor asked why the staff continued to apply Santyl and Silvadene, did one not counter act the other. The response was the pharmacy staff were not told to stop one wound care to begin another.

An interview was conducted with EI # 6, Surgeon on 1/16/13 at 12:30 PM. The surveyor asked if EI # 6 expected the staff to stop using one wound care order before starting another. EI # 6 stated, "Yes I would. They did didn't they?" The surveyor told EI # 6 that the staff were using both Santyl and Silvadene at the same time. EI # 6 stated, "Oh no."

The pharmacist submitted documentation to the surveyor on 1/16/13 at 3:30 PM which stated, " A search on the Internet sources revealed some information related to a possible interaction where the debriding activity of Santyl could be reduced in combination with Silvadene..."

Based on observations and interviews it was determined the infection control officer failed to ensure all infection control policies and standards were followed by the staff. This affected Patient Identifer # 1 and 3 and had the potential to negatively affect all patients served by this facility.

Refer to A 748

Based on observations and interviews it was determined the infection control officer failed to ensure all infection control policies and standards were followed by the staff. This affected Patient Identifer # 1 and 3 and had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: Dressing Change Issued 4/5/10

1. Purpose: To establish guidelines for wound dressing changes.

2. Philosophy: It is our belief that proper wound dressing changes minimize the potential for infection and promote patient comfort and wound healing.

3. Standards:

3.5. Universal Precautions shall be followed during dressing change.

4. Procedure:

4.6. When doing multiple wound dressing changes, follow procedures and do each dressing change separately to prevent cross contamination.

4.7. Wash Hands

4.8. Put on non-sterile gloves.

4.10. Remove soiled dressing and place in plastic bag.

4.11. Remove soiled gloves.

4.12. Wash hands.

4.14. Apply gloves.

************

Centers for Disease Control (CDC) Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings

What Type of PPE Would You Wear?

Drawing blood from a vein? Gloves

************

Facility Policy: Infection Control

OSHA (Occupational Safety and Health Administration) Bloodborne Pathogen Standard

Exposure Control Plan dated 7/30/08

Standard Precautions

1. Healthcare Personnel Hand-Washing

4. Decontaminate hands in the following situations:

h. After removing gloves...

III. Gloves:

B. Gloves must be worn:

1. When there is likelihood of hand contact with blood and any secretions or other potentially infectious materials.

2. During all vascular access procedures.



A tour of the Emergency Department (ED) was conducted on 1/16/13 at 1:30 PM. The surveyor reviewed the ED logs for 2013 and requested 10 medical records to review.

During observation of care provided on 1/16/13 from 1:30 PM to 3:00 PM the surveyor observed the following:

1. Employee Identifier (EI) # 8, ED Nurse was observed placing linen in the dirty linen container with a gloved hand. EI # 8 then went back to the patient care area without hand hygiene.

2. EI # 8 then left the patient care area without hand hygiene and began documenting in the computer.

3. EI # 8 was observed obtaining blood via left antecubital space with a butterfly needle without gloves.

4. A step stool was observed in ED room # 101 with a red blood appearance stain.

5. Several room were observed being cleaned between patients. When the stretcher in each room was cleaned the staff did not clean under the mattress.

6. During observation of ED room 101 being cleaned between patients, a staff member was observed placing a urinal with approximately 200 cc (cubic centimeters) of urine in the regular trash.

An interview was conducted with EI # 7, ED Director on 1/16/13 at 2:45 PM. EI # 7 stated recognition of 1 of 10 ED records pulled by the surveyor. The surveyor asked which patient it was and the response was PI # 3. The surveyor then asked why he/she recognized PI # 3. EI # 7 stated that the Charge Nurse called him on 1/7/13 to inform EI # 7 of a incidence with PI # 3. EI # 7 stated that PI # 3 sat on the stretcher and a few minutes later realized her clothes were wet from the previous patient's urine. EI # 7 stated that the mattress was not cleaned underneath and the urine from the previous patient was left.

Facility Policy: Dressing Change Issued 4/5/10

1. Purpose: To establish guidelines for wound dressing changes.

2. Philosophy: It is our belief that proper wound dressing changes minimize the potential for infection and promote patient comfort and wound healing.

3. Standards:

3.5. Universal Precautions shall be followed during dressing change.

4. Procedure:

4.6. When doing multiple wound dressing changes, follow procedures and do each dressing change separately to prevent cross contamination.

4.7. Wash Hands

4.8. Put on non-sterile gloves.

4.10. Remove soiled dressing and place in plastic bag.

4.11. Remove soiled gloves.

4.12. Wash hands.

4.14. Apply gloves.

************

CDC Guidelines for Bloodborne Pathogens
by Beth Celli, eHow Contributor

Bloodborne Pathogens

Bloodborne pathogens are microscopic organisms (or microorganisms) that can cause illness in people. They are found in the blood or other body fluids. Human immunodeficiency virus (HIV) which causes AIDS, and hepatitis B virus (HBV), are two of the most common bloodborne pathogens. These diseases and others pose a serious threat to health care workers.

Management of Waste

All materials that are contaminated with blood or body fluids should be disposed of in a red bag, or biohazard trash...


1. PI # 1 was admitted to the facility on 12/24/12 with admitting diagnoses including Cholecystitis, Possible Common Bile Duct Obstruction, Ileus, Hypertension, and Back Pain.


Review of the Operative Note dated 1/15/13 ( which should have been 1/14/13) revealed documentation as follows, "...we debrided the heel all the way down to the bone and bleeding tissue...It was a eschar with some wet and dry gangrene noted. We excised it all the way down to the bone...then the second toe on the right foot had what looked like an infection area over the top of the toe. I was able to debride it all the way down to the bleeding tissue..."

An interview with Employee Identifier ( EI) # 2, Chief Nursing Officer on 1/15/13/at 10:40 AM when the surveyor asked for wound measurements, photo, and description. EI # 2 was unable to locate any documentation of the wound description of any kind. EI # 2 stated there should have been photos on admission, measurements, descriptions of the wound and surrounding tissue.

On 1/16/13 at 7:50 AM the surveyor reviewed the medical record and there was no documentation of wound measurements, a photo, or a description.

The surveyor then requested to see the wound. EI # 2 and EI # 3 , Registered Nurse went to PI # 1's room with gauze and normal saline (NS). EI # 2 removed the dressing from the left heel. There was approximately a 5 cm (centimeter) ring of dried blood on the old dressing. EI # 2 threw the dressing in the regular trash. EI # 2 measured the wound 5 cm long, 4 cm wide, and 1/2 cm deep with blood red tissue. Bone was exposed.

EI # 2 cleansed the wound to the left heel and then covered the wound with gauze moistened with NS with the same pair of gloves used to remove the old dressing. EI # 3 then wrapped the wound to the left heel. EI # 3 then removed the dressing from the left great toe and was waiting for EI # 3 to return with more gauze. The left great toe was dripping blood on to the linen. EI # 3 then placed gauze under the toe to catch the dripping blood. After EI # 3 dressed the left great toe EI # 3 threw the gauze the toe had been dripping on in the regular trash.

EI # 3 then removed the dressing from the right 2nd toe with the same pair of gloves used to remove the dressing from the left great toe. EI # 3 then dressed the left great toe and the right 2nd toe using the same gloves.