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Based on record review and interview the facility failed to ensure staff evaluate and treat pressure ulcers according to the facility's policy/procedure for Pressure Ulcers dated 10/1/2015;

The facility failed to do singlestick tests to monitor glucose according to physician's orders. Citing two (2) patients named in complaints (#2 and 3).

Findings:

Patient #2
Review of complaint narrative revealed information Patient # 2 was discharged home from the facility wearing large boots on both feet. When the boots were removed the patient's feet were bad, black from the heels covering the entire foot. He had broken blood blisters on the heels.

The family alleged the hospital staff did not tell the family the patient had sores on his feet.
Review of the patient's history and physical revealed the patient was admitted to the facility on 10/28/2015 from an acute care facility with history of multiple strokes with multiple contractors and general weakness.
The patient had a healed sacral ulcer with red escarp of about 2 x 1.5 cm. There was no mention of heel involvement.
Review of Physician progress notes dated 10/28/2015 revealed documentation the patient had a healed sacral ulcer. There was no documentation the patient had heel ulcers.
Review of nursing admission assessment revealed there was no documentation that the patient had pressure ulcer on any part of his body.
Review of Physician's Progress notes dated 11/3/2015 revealed the 4 following notes: ''Diabetic foot, patient will continue pressure ulceration prevention, keep her on air mattress''.
Review of nurses notes dated 11/7/2015 revealed documentation the patient had blisters on bilateral heels.
Review of Physical Therapy notes dated 11/7/2015 revealed documentation that a wound screen was done on request of the Registered Nurse.
The screen notes revealed the patient had bilateral large suspected deep tissue injury of heels.

No break in the skin present. Heels photographed and placed on chart. Additionally provide patient with multi-pods boots in order to elevate heels to increase capacity to heal.

Nursing assessment notes dated 11/7/2015 documented the patient had off load boots applied by wound care to bilateral heels.

Nursing assessment notes dated 11/7/2015 documented the patient had off load boots applied by wound care to bilateral heels.

There was no documentation the physician was informed the patient had pressure ulceration of the heels.
There was no documentation the patient's family was informed the patient had pressure sores on her heels.
Review of the photographs which were in color, revealed large reddened area of both heels with splashes of discoloration on the heels.

Review of Nurses' notes dated 11/8/2015 and 11/9/2015 revealed documentation the patient had blisters on bilateral heels. There was no other description of the pressure sore.

Review of nurses notes dated 11/10/2015 through 11/19/2015 when the patient was discharged revealed no documentation that the condition of the patient's heels were evaluated and what treatment was required.
There was no orders by the physician for treatment of the pressure ulcers on the heels.
Review of nursing documentation dated 11/19/2015 revealed information the patient had multi pods boots, there was no mention of the condition of the patient ' S heels.
Review of physician's discharge summary dated 11/19/2015 revealed information
the patient had ''bilateral heel ulcerations which were treated with zinc oxide and heel protectors''.
Review of treatment notes and physician ' S orders dated 11/7/2015 - 11/19/2015 revealed no evidence that there was an order for zinc oxide treatment nor that this treatment was implemented.
Review of discharge planning notes and discharge instructions on date of discharge revealed no mention of pressure ulcers of heels.
During an interview on 3/4/2016 at 11:10 am at the facility with the Director of Patient Care she stated staff would be retrained on pressure ulcer assessment and management.
Policy Review
Review of Pressure Ulcer Prevention and Treatment policy and procedure PC/PS 073 10/1/2015 require staff to:
''Perform and document a skin assessment on all patients daily.
Assess and document patient's level of pain over bony prominence.
Utilize protective dressings to decrease friction, paying close attention to the heels, i.e. transparent films, hydrocolloids, foam dressing.
Implement family/patient education; Encourage family and /or patient involvement in patient care and management program.
Wound must be assessed and documented upon admission, with each dressing change, and upon discharge''


Patient # 3
Review of complaint narrative revealed information Patient # 3 had Physician's orders requesting finger sticks to be done twice a day was not carried out.
Instead staff were doing the tests four times a day sticking the patient unnecessary additional number of times a day.
Review of physician's orders dated 9/22/2015 revealed an order for finger sticks for blood sugar monitoring to be done every six (6) hours. (Four times a day).
The orders were changed on 10/1/2015 for finger sticks for glucose monitoring to be done every 0600 and 1800 daily. (Twice a day)

Review of Nurses' notes dated 10/2/2015-10/15/2015 revealed several days after the order was changed , staffs were still doing finger sticks for blood glucose monitoring four (4) times a day instead of two times a day and at other times only once a day with no reason documented.

Review of glucose monitoring documentation on the clinical record revealed the normal reference range was 73-104.
Review of blood sugar tests and results revealed the following information:
On 10/2/2015 the blood sugar test was not done for the morning it was done 17:54 and was 84 mg/dl.
On 10/4/2015 the test was done at 06:40 and was 82 mg/dl the evening test was not done.

On 10/5/2015 the tests were done at 04:55 am (84 mg/dl), 12:08 PM (93 mg/dl), 16:21pm, and 20:12pm four (4) times with no documented reason.

On 10/14/2015 the tests were done at 03:52, 11:46, and 16:33 with results 83-98 mg/dl within normal range (3 times)

10/15/2015 done at 00:29, 03:45, 16:27, range was 91-104 mg/dl within normal limits no documented reason for four (4) sticks.

During an interview on 3/4/2016 at 9:45 am at the facility with the Charge Nurse he stated looking at the orders and how it was transcribed it appeared the original order was not discontinued, as a result some individuals were continuing the old orders while others were carrying out the new orders.

This mistake was not identified by the staff conducting daily chart reviews.

Based on observation , interview and record review the facility failed to ensure staff sanitize equipment used for a patient on contact isolation after use;
The facility failed to educate staff to use gloves when handling patient's eating utensils that could potentially be contaminated.
This failed practice had the potential for the spread of infection to staff and patients on the unit. Citing one (1) random observation. (Staff Q).
Findings:
Observation on 3/3/2016 at 1:15 pm on Medical Surgical Unit revealed the following information:

Staff (Q ) Registered Nurse (RN) RN was observed in the room of Patient (# 1)providing care.

There was a sign on the door to the patient's room with information the patient was on Contact Isolation.
Observation revealed the Nurse was administering parenteral medication and other care activities to the patient.

She had gown and gloves on while in the patient's room.
The staff was seen touching items in the patient's room including bed,the patient's person, and over bed table.

Observation revealed Staff (Q) RN was using a work station on wheel (WOW) inside the patient's room which also consisted of a computer and keyboard which she was making documentation on with gloved hands.

After completing her task in the patient's room Staff (Q) left the patient's room with the WOW, placed it in the hallway where work stations on wheels were stored. She did not clean and sanitize the cart after use.

Staff (Q) removed a used tray with dishes from the patient #1's room and did not wear gloves to handle the used tray.
During an interview on 3/3/2016 at 2:10 pm on the unit with the Infection control officer, the Director of Quality and the Charge Nurse regarding the staff handling the used tray without gloves the staffs all stated gloves was not required to remove the used tray from the contact isolation room because the staff would be wearing PPE outside the patient's room.
During an interview with the Director of Patient Care for the hospital she stated Staff (Q) should have sanitized the work station on wheels (WOW) immediately after use.

She stated she was not sure the staff was required to wear gloves when handling the used tray when removing it from a room where the patient was on Contact Isolation.

Review of progress notes for Patient # 1 revealed the patient was on contact isolation for MRSA (Methicillin-Resistant Staphylococcus Aureus) infection of the sputum and respiratory.( Transmissible to eating utensils used by the patient).
Review of the facility ' S Infection Control Policy/Procedure dated 4/13/2015 revealed the following information:

''Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources or infection.

Wear clean non-sterile gloves when touching blood, body fluids, secretions, excretions and any items contaminated with these fluids;

Put on clean gloves just before touching mucous membranes and non intact skin.
Re-usable patient care equipment that becomes soiled with blood or body fluids will be placed in a plastic bag taken to the soiled utility room for cleaning before being used on another patient.''