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Based on observation, medical record review, staff interview and policy and procedure, the facility failed to ensure that patient #1 was turned and repositioned routinely to promote healing of existing pressure ulcers and to avoid developing new pressure ulcers. One (1) of one (1) patient was affected.

Findings

The facility ' s Skin and Wound Care Policy and Procedure with the effective date of 04/20/2010 contained the following requirements. Page one: B. If the patient is noted to have a pressure ulcer or the patient scores 16 or less on Braden Scale, the problem " Skin Integrity Actual or Potential Impaired " is initiated and nursing prevention measures are initiated. These preventive measures may be found in the physician ' s orders specific to the type of the wound and may include: Turn at least every two hours. " Page two: Suspected Deep Tissue Injury: " Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or sheer. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent. "

Patient #1: Observation on 5/19/2010 from 10:00 a.m. to 10:50 of the treatment nurse providing pressure ulcer assessment and care revealed the following information. A dark purple 4 centimeters (cm) by 7 cm pressure ulcer was on the left heel. A 1 cm by .6 dark purple was on the right foot proximal to the great toe. Review of the facility ' s Braden Score for Predicting Pressure Risk assessment required the stage of Deep Tissue Injury to be recorded as " D. " There was no documentation that the patient had deep tissue damage pressure ulcers. Review of the Adult Nursing Admission Assessment contained the following information. The patient was admitted to the facility on 5/18/2010 at 6:30 p.m. with diagnoses of dehydration and Renal failure and history of stroke. Patient problems included: contractures to bilateral lower extremities; a 3 cm stage II pressure ulcer to the right hip; a 3 cm stage II pressure ulcer to the left ankle; a 4 cm by 7 cm stage I pressure ulcer to the left heel; and a 1 cm stage one to the right outer foot. The patient was bed fast and completely immobile. The Interdisciplinary Plan of Care identified the need to turn the routinely. The frequency that the patient was to be turned was not documented. Record review revealed that there was no documented evidence that the patient was routinely turned and repositioned.

The finding of no documentation of routinely turning the patient was discussed with Registered Nurse #1 on 5/19/2010 from 10:55 a.m. to 11:00 a.m. He reviewed the patient ' s chart at that time and reported agreement with surveyor findings. Findings were again discussed the Clinical Affairs Registered Nurse on 5/19/2010 from 11:50 a.m. to 12:00 p.m.

Based on medical record review, staff interview and policy and procedure review, the facility failed to follow the care plan to turn patient #1 routinely to facilitate healing of pressure ulcers and to prevent developing new pressure ulcers. One (1) of one (1) patient was affected.

Findings include:

Patient #1: Review of the Nursing Admission Assessment the following information. The patient was admitted to the facility on 5/18/2010 at 6:30 p.m. diagnoses of dehydration and Renal failure and history of stroke. Patient problems included: contractures to bilateral lower extremities; a 3 centimeter (cm) stage II pressure ulcer to the right hip: a 3 cm stage II pressure ulcer to the left ankle; a 4 cm by 7 cm stage I pressure ulcer to the left heel; and a 1 cm stage one to the right outer foot. The patient was bed fast and completely immobile. Review of the Interdisciplinary Plan of Care revealed that the need for the patient to be turned the routinely was identified. The frequency that the patient was to be turned was not documented. Record review revealed that there was no documented evidence that the patient was routinely turned and repositioned. The findings were discussed with Registered Nurse #1 on 5/19/2010 from 10:55 a.m. to 11:00 a.m. At that time he reviewed that medical record and reported agreement with surveyor findings.

This STANDARD is not met as evidenced by:

Based on observation and staff interview the hospital failed to provide proper storage of medication that is routinely given to newborns during the transition period of birth in the nursery.

FINDINGS:

On 5/18/10 at 11:20 am on tour of the nursery this surveyor observed that the Erythromycin Ophthalmic Ointment that is routinely used in the newborns eyes after birth was stored in the refrigerator with temperatures ranging from 38-40 degrees Fahrenheit.

A review of the medication insert for Erythromycin Ophthalmic Ointment found with the medication revealed that this medication should be stored 15-30 C (59-86 F)

On 5/18/10 at 11:25 am the RN in the nursery revealed that the Erythromycin Ophthalmic Ointment is always slightly warmed before instilling in newborns eyes. The RN revealed that a few months ago there was a shortage of Erythromycin Ophthalmic Ointment. The RN revealed she was told by the Pharmacist to keep the ointment in the refrigerator to keep up with it better.

On 5/18/10 the above findings were discussed with the Pharmacist and DON. No additional documentation was offered. The Pharmacist stated, " I threw all the ointment in the refrigerator in the garbage. "

Based on medical record reviews and review of the diet list for May 19, 2010, the facility did not meet the nutritional needs of the patients in accordance with recognized dietary practices and in accordance with orders of the practitioner responsible for the care of the patients.

In reviewing the patients' diet orders on their medical records and comparing them to the orders on the Diet List for May 19, 2010, there were discrepancies between the diet orders on the medical records and the Diet List.

1. On patient number 1 the order on the medical record stated that the patient was to receive a 2000 calorie ADA diet and a 2 gm NA diet. The order on the diet list stated only that the patient was to receive a 2000 calorie diet with chopped meat.

2. On patient number 2 the order on the diet list stated that the patient was to receive a 1600 calorie ADA diet and a low NA diet. There was no order for the low NA diet on the patient's medical record.

3. On patient number 3 the order on the diet list stated that the patient was to receive a 1800 calorie ADA diet only. The order on the medical record for patient number 3 stated that they were to receive an 1800 calorie ADA diet plus a 2 gm. low NA diet.

Based on observation and interview with facility staff the hospital failed to be arranged and maintained in such as manner as to ensure the safety of the patient. The hospital failed to meet the applicable provisions of the 200 Edition of the LSC. Refer to A 709 and K 11, K 12, K 17, K 20, K 21, K 25, K 29, K 32, K 33, and K 52.

The hospital failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association. Refer to Refer to A 709 and K 11, K 12, K 17, K 20, K 21, K 25, K 29, K 32, K 33, and K 52.

Based on observation the hospital failed to properly store its biohazardous waste.

On 05/19/2010, at approximately 10:30 a.m. the surveyor observed the two biohazardous waste storage areas in the Radiology Department. Both areas were observed to be unlocked. One of the doors to a biohazardous waste storage area was not equipped with a locking device. Infectious medical waste shall be so secured so as to discourage
access by unauthorized persons.

Based on record documentation, observation during tour of hospital, interview with staff, and written statements from staff the hospital failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases for four (4) out of four (4) patients reviewed. Patient #1, 2, 3, and 4 were affected. The hospital failed to ensure that the infection control protocols, policies/procedures and staff be alert to prevent, control, and investigate communicable diseases.

FINDINGS:

On 5/18/10 at 10:00 am review of patient number one (1) clinical record revealed that this patient was admitted 5/18/10 at 5:46 am to the labor and delivery room for induction of her third baby. Review of admission form Interdisciplinary Plan of Care for Labor and Delivery page three revealed that this patient had a history of MRSA. Surveyor asks the registered nurse (RN) taking care of this patient about the MRSA finding. The RN in charge of this patient revealed that she was not aware of the MRSA posted in the chart. The RN revealed that when a patient has a history of MRSA the computer triggers a flag noting such on the admission documentation. (Patient number one (1) is not in any type of isolation at this time.)

On 5/18/10 at 10:15 am the Director of Nursing (DON) called the ICN and asked him to come to the Labor and Delivery Department (L/D).

On 5/18/10 at 10:30 am the ICN revealed that he had not looked at his report on the Infectious Disease Census for 5/18/10 because he was busy admitting a patient. The ICN revealed that the admitting nurse should have put the patient on contact isolation on admission. The ICN revealed that it is the policy of the hospital for the admitting nurse to place all patients with history of MRSA on contact isolation and obtain a nasal swab culture. He also revealed that the computer will trigger a note to the person admitting the patient if a known history of MRSA exists.

On 5/18/10 at 10:40 am patient number one (1) was placed on contact isolation per the nursing staff.

Review of Contact Precautions that was placed on the door of patient number revealed that gloves are required, not optional, when you enter a room.

On 5/18/10 at 10:45 am this surveyor observed a RN at patient number one ' s (1) bedside working with the patient ' s IV without gloves on her hands or wearing an isolation gown.

On 5/18/10 at 10:45 am this surveyor with assistance of the DON called and interviewed the RN that admitted patient number one (1) to L/D at 5:46 am. The RN revealed that the house supervisor did tell her about patient number one ' s (1) history of MRSA before the patient came to the L/D department. She then stated, " we don ' t have patients with MRSA very often, but usually the patient would be put in isolation until the report from the lab came back verifying the MRSA status " .

On 5/10/10 patient number two (2) was admitted to room 223 with Renal Failure and Post Cardiac Event. On 5/18/10 at 3:30 pm a tour of the medical floor was performed by surveyor. The ICN revealed that this patient was found to have MRSA on 5/17/10 when he received the lab sputum results. Surveyor asked the ICN if he informed nurses on the floor of his finding. He replied, " no I did not " . The charge nurse reported that patient number two (2) was placed in contact isolation earlier today 5/18/10 as ordered by ICN.

On 5/17/10 patient number three (3) was admitted to the medical floor with a history of MRSA. On 5/18/10 patient was placed on contact isolation due to history of MRSA.

On 5/18/10 an interview with the charge nurse indicated that she helped with the admission of patient number three (3) at 6:40 pm on 5/17/10 change of shift. She revealed that she received a call that the patient had a history of MRSA. She told the LPN at the night shift report to place the patient in isolation.

On 5/17/10 patient number four (4) was admitted to the medical floor with a history of MRSA and placed on contact isolation. On 5/18/09 an order for a nasal swab was ordered by the ICN. The charge nurse revealed she was aware that she should have obtained a nasal swab culture on admission, however, she forgot to do so.

On 5/18/10 a statement from the charge nurse revealed that patient number two (2) was admitted to room 223 on 5/10/2010 at 12:30 pm with diagnosis of chest pain to rule out Myocardial Infarction. No MRSA contact isolation noted. On 5/14/2010 at 3:00 pm patient was transferred to room 322 per physician ' s order. No MRSA contact isolation noted during this transfer. On 5/15/2010 at 6:15 pm the patient transferred to room 206 per physician ' s order due to documented complaint of chest pain per nurse ' s note. No MRSA contact isolation noted. On 5/18/2010 at 12:00 noon patient placed on MRSA contact isolation by nurse after notification and written order from Infection Control Director. The Charge Nurse informed surveyor that this patient had a history of MRSA found in the stool

On 5/19/10 at 11:00 am an interview with the ICN was conducted. The ICN stated, " I looked at lab results every day. Yesterday I planned on putting all the 5 patients you questioned about on contact isolation; you just beat me to it. "

Review of Policy and Procedure on Infection Controls revealed the following:
" Purpose: To reduce the likelihood of transmission of multi-drug resistant organisms ...
Procedure: (1) The attending physician and/or transferring facility should notify NWMRMC at the time of admission of a known or suspected multi-drug resistant organism patient. (2) Patients known or suspected to have a multi-drug resistant organism infection or colonization will be placed on Contact Precautions. Droplet Precautions will be added for any respiratory infection. (3) The Director of Infection Control may order cultures necessary for the investigation of known or suspected MRSA/VRE. (4) Prior colonization or infection history should be obtained during the nursing admission assessment. (5) The Director of Infection Control will notify all facilities that transfer patients with unknown cases of multi-drug resistant organisms to NWMRMC once the diagnosis is made. (6) An appropriate precautions sign should be posted at the entrance to the room. (7) All unnecessary equipment is to be removed from the room prior to patient placement. Identification of Patients with Multi-Drug Resistant Organisms: (1) The Lab will notify both the Nursing Unit and the Director of Infection Control when a positive culture for MRSA, VRE, or ESBL is identified. (2) The Lab will notify the Primary Care physician of multi-drug resistant organism cultures in the event the patient is discharged prior to identification of organism. (3) The Director of Infection Control manages the Infections Disease Tracking System ... (4) The Director of Infection control and Nursing Supervisor will monitor a daily query MRSA list to make sure patients identified by flagging system are isolated ... "

On 5/19/10 at 4:00 pm the DON and Infection Control Nurse was advised of the above concerns. No additional documentation was offered.

On May 19, 2010 at 12:15 P.M., a Life Safe Code inspection of the kitchen was conducted by the Life Safety Code Surveyor. While inspecting the kitchen area, the surveyor observed a door behind the kitchen exhaust hood. This door is where the gas fired equipment is stored. Upon opening the door the surveyor observed a rat running up the wall into the ceiling.