HospitalInspections.org

Based on record review and interview, the facility failed to ensure there are updated and individualized care plans for patients based on patient assessments in 6 of 6 diabetic patient medical records (1, 7, 8, 10, 12 and 14) out of a total 14 medical records reviewed. The Cumulative effect of these deficiencies potentially affect all patients treated at the facility.

Findings include:

The facility failed to ensure that there is an updated, comprehensive care plan that is individualized with appropriate nursing interventions and ongoing assessments of patient's needs and response to interventions. In 6 of 6 diabetic patient medical records (1, 7, 8, 10, 12 and 14) out of a total 14 medical records reviewed. See tag A396.

Based on record review and interview the facility failed to ensure that a comprehensive care plan that is individualized, and based on assessing the patient's nursing care needs, treatment goals, admitting diagnosis', has appropriate nursing interventions with ongoing assessments of patient's needs and response to interventions. In 6 of 12 in a total universe of 14 (1,7,8,10,12 and 14) medical records reviewed. This has the potential to affect 29 inpatients present during survey.

Findings include:

The facility policy titled "Nursing Care Plan" #NO2-N dated 4/17 reviewed 6/20/17 at 9:25 AM page 2 under "Procedure" #2 "On the 24 Hour Patient Record and Plan of Care form the nurse will implement and document approaches related to key nursing care issues and establish short term goals based on the nursing assessment findings." The policy on page 3 continues to list "Care Guidelines" and "Problems and Approach" including Malnutrition: Protein Wasting, Calorie Deficiency, Bone loss, Glycemic Control, Management and Protection from Infection, Myopathy of Critical Illness, Wounds, Delirium/depression and Symptom Burden and Suffering. Under "Glycemic Control" states "1. A clear plan to manage needs to be established. 2. Meticulous follow-through with management strategy needs to happen. 3. Interruptions in feeding must be considered before insulin administration. 4. Daily assessment of changing needs as CCIS (Chronic Critically Ill) resolves, insulin supplement needs should decrease."

Patient # 1's medical record was reviewed on 6/20/17 at 9:00 AM Patient #1 has admitting diagnosis on admission history and physical of cerebral abscess, debility, acute hypoxic respiratory failure, pseudomonas ventilator-associated pneumonia, severe protein-calorie malnutrition, dysphagia, diabetes mellitus type 2, hyperlipidemia, anemia, left upper extremity peripherally inserted central catheter, and acute kidney injury. Patient #1 was also receiving nasogastric tube feedings 6 PM to 6 AM and a mechanically altered diet requiring 1:1 supervision, nectar thick liquids, and to be sitting upright 90 degrees with all meals. On review of "Plan of Care" dated 4/29/17 (date of admission- date of transfer 5/2/17) active care plan problems included the following: Knowledge deficit, alteration in mental status, alteration in comfort, alteration in sensory perception, potential for infection, alteration in elimination, potential for physical injury/fall risk, self care deficit, alteration in skin integrity and potential nutrition risk. Review of the 24 hour nursing assessment page one had area for documentation on vital signs and blood sugars that has no entries and a large "X" marked through this area on all 4 days that patient was an inpatient (4/29-5/2/17). The problems and interventions on the pre printed "Plan of Care" do not address the dietary orders, 1:1 assist with meals, 90 degree head of bed with meals, blood sugar monitoring, insulin administration, or nasogastric tube feedings with problems, goals or interventions.

Patient # 7's medical record was reviewed on 6/20/17 at 11:10 AM Patient # 7 has admitting diagnosis of aspiration pneumonia, diabetes, permanent tracheostomy, history of seizures and incontinence. Review of the 24 hour nursing assessment page one has area for documentation on vital signs and blood sugars that has no entries and a large "X" marked through this area on all days that patient was an inpatient. The problems and interventions on the pre printed "Plan of Care" do not address the tracheostomy care, blood sugar monitoring, insulin administration, gastric tube feedings, seizure precautions or incontinence with problems, goals or interventions.

Patient # 8's medical record was reviewed on 6/20/17 at 12:30 PM Patient #8 has admitting diagnosis of peri rectal abscess and history of diabetes, dysphagia, chronic obstructive pulmonary disease, depression and a wound receiving treatment. Review of the 24 hour nursing assessment page one has area for documentation on vital signs and blood sugars that has no entries and a large "X" marked through this area on all 4 days that patient was an inpatient. The problems and interventions on the pre printed "Plan of Care" do not address the blood sugar monitoring, insulin administration, dysphagia (difficulty swallowing), or depression with problems, goals or interventions.

Patient # 10's medical record was reviewed on 6/21/17 at 9:30 AM Patient #10 has admitting diagnosis of respiratory infection with a history of dysphagia (difficulty swallowing), depression, multiple sclerosis, cognitive impairment, chronic pain and methicillin staph resistant infection. The problems and interventions on the pre printed "Plan of Care" do not address the cognitive deficit, dysphagia (difficulty swallowing), depression, chronic pain, or multiple sclerosis with problems, goals or interventions.

Patient # 12's medical record was reviewed on 6/21/17 at 11:20 AM Patient # 12 has admitting diagnosis of multivessel coronary artery disease after a cardiac arrest while on hemodialysis, with a history of diabetes, atrial fibrillation (cardiac arrhythmia) requiring anticoagulant medications, placement of an automated defibrillator, end stage renal disease requiring hemodialysis, hypertension, dyspnea (shortness of breath), Parkinson's disease, depression and anxiety. Review of the 24 hour nursing assessment page one has area for documentation on vital signs and blood sugars that has no entries and a large "X" marked through this area on all days that patient was an inpatient. The problems and interventions on the pre printed "Plan of Care" do not address the blood sugar monitoring, insulin administration, hemodialysis, use of anticoagulation medications and potential for bleeding, depression and anxiety with problems, goals or interventions.

Patient # 14's medical record was reviewed on 6/21/17 at 8:55 AM Patient # 14 has admitting diagnosis of bowel resection and a history of diabetes. Review of the 24 hour nursing assessment page one has area for documentation on vital signs and blood sugars that has no entries and a large "X" marked through this area on all days that patient was an inpatient. The problems and interventions on the pre printed "Plan of Care" do not address the blood sugar monitoring or insulin administration with problems, goals or interventions.

An interview was conducted with Chief Nursing Officer C on 6/20/17 at 9:15 AM who stated that the 24 hour nursing assessment is part of the care plan and that is where blood sugars/insulin and diabetes is addressed. Chief Nursing Officer C was questioned on diabetes diagnosis not being addressed on care plan stated "it is addressed on the 24 hour assessment done shiftly by the nurse" (area with the hand written "X" through it) Chief Nursing Officer C explained that vital signs are done electronically and the 24 hour assessment is still hand written. Discussed that care planning addressing diabetes was not filled out Chief Nursing Officer C stated "I see what you mean".

Based on observation, record review and interview the facility failed to ensure there is a comprehensive infection control program that includes surveillance to prevent the potential of contamination and/or cross contamination, in 2 of 2 staff observed (M & N). This deficiency directly affects Patients # 13 & 15 and potentially affects all 29 inpatients during complaint investigation.

Findings include:

Per interview with Director of Quality Management A on 6/29/17 at 3:00 PM regarding the standards of practice followed by nursing services "Our policies are based on the CDC recommendations found in the "Appendices from Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007". This standard of practice states on page 48 "It may be necessary to change gloves during the care of a single patient to prevent cross-contamination of body sites" and "Hand hygiene following glove removal further ensures that the hands will not carry potentially infectious material that might have penetrated through unrecognized tears or that could contaminate the hands during glove removal".

The facility's policy entitled "Hand Hygiene" #IC 111-2 dated 7/16 was reviewed on 6/21/17 at 1:00 PM, on page 1 under "How" describes two acceptable methods of hand hygiene: soap (detergent) and water and an alcohol based hand rub. Under "When" hand hygiene should be done: beginning with bullet point #2 "Before and after every patient contact. Between patient care activities within the same episode of care. Before donning either sterile or non-sterile gloves. Between glove changes and after removing gloves. After any contact with body fluids, dressings, patient linen. Before any patient procedure or medication administration."

On 6/21/17 at 12:00 PM observed Registered Nurse M administer to Patient #15 an intravenous normal saline flush then proceeded to go gastric tube flush with water without changing gloves or performing hygiene between patient care activities within the same episode of care.

On interview with Chief Nursing Officer C 6/21/17 at 1:30 PM verbalized agreement that glove change and hand hygiene should have been completed between tasks.

On 6/21/17 at 12:20 PM observed Registered Nurse N administer to Patient #13 an intravenous antibiotic and prior to connecting Registered Nurse N dropped supplies on the floor, picked up supplies, threw away supplies and changed gloves without performing hand hygiene prior to donning new non-sterile gloves and completing intravenous antibiotic administration.

On interview with Chief Nursing Officer C 6/21/17 at 1:30 PM verbalized agreement that hand hygiene should have been completed prior to donning new gloves.