HospitalInspections.org

I. Based on medical record review, policy review and staff interview, it was determined that nursing staff failed to provide care as ordered by the physician for 3 of 4 patients (Patient #'s 1, 2 and 4) in the sample. Findings include:

The hospital "Job Description" for the Registered Nurse (RN) documented the following, "...integrates the medical care plan into the provision of nursing care...Provides nursing care to meet patient's needs...Adheres to established policies and procedures of the hospital..."

The hospital policy entitled "VAP (Ventilator Associated Pneumonia) Bundle" stated, "...Nursing and/or RT (respiratory therapist) will provide oral care every 4 hours..."

The hospital policy entitled "Trach (tracheostomy) Care" stated, "...All patients with an artificial airway should receive tracheostomy care upon admission, then BID (twice daily) and PRN (as needed)..."

The hospital policy entitled "Guidelines and Protocols, Clinical" stated, "...Routine/Guidelines Minimum Frequency...Oral care for vent (ventilator) patients Every 4 hours and PRN...Trach care Every shift and PRN...Measurement and documentation of wounds...every 7 days..."

Medical record review revealed:

A. Patient #1

1. "Admission Orders" dated 2/3/16 included:- Vital signs to be obtained every 8 hours
- Mechanical Ventilator
- Tracheostomy care to be performed BID
- Nursing and/or Respiratory Therapist to provide oral care every 4 hours

2. "Telephone or Verbal Order" dated 3/17/16:
- Sacral/coccyx (wound): Irrigate with normal saline, pat dry, apply skin prep to periwound. Apply skin prep to periwound. Apply Medihoney (wound treatment) to wound. Cover with foam adhesive.

3. Vital signs were not obtained every 8 hours on the following dates: 2/9, 2/10, 2/12, 2/17 and 2/29/16

4. No evidence that tracheostomy care was provided BID on the following dates:2/4, 2/13, 2/14, 3/17, 3/20 and 3/21/16

5. No evidence that oral care was provided every 4 hours on the following dates: 2/10, 2/14, 2/18, 2/23, 2/26, 2/28, 2/29 and 3/9/16

These findings were confirmed by Director of Quality Management A on 5/18/16 between 3:15 PM and 3:45 PM.

6. No evidence that the physician's order, dated 3/17/16, for sacral wound care was implemented 3/17 through 3/24/16 (8 days).

This finding was confirmed by Wound Care RN A and Director of Quality Management A on 5/19/16 at 1:45 PM.

B. Patient #2

1. "Admission Orders" dated 5/11/16 included:
- Vital signs to be obtained every 8 hours
- Tracheostomy care twice daily and as needed

2. Vital signs were not obtained every 8 hours on the following dates: 5/11, 5/12, 5/13, 5/14, 5/15, 5/16 and 5/17/16

3. No evidence tracheostomy care was provided twice daily:
- 5/11 and 5/12/16

These findings were confirmed by Director of Quality Management A on 5/18/16 at 5:00 PM.

C. Patient #4

1. Physician Orders
a. "Admission Orders" dated 10/8/15 included: - Tracheostomy care twice daily
- Mechanical ventilator on assist control setting
- Vital signs to be obtained every 4 hours

b. 10/8/15: "...irrigate sacral wound c (with) normal saline, place Medihoney/Adaptic/Gauze and Tegaderm (sterile transparent adhesive dressing) daily"

c. 10/12/15 at 11:00 PM wound care orders:
- Right arm: to be cleaned with normal saline solution (NSS), Medihoney applied, and then covered with adhesive foam
- Sacrum: NSS, Skin prep, Medihoney/adhesive foam
- Right Lower Extremity (RLE): NSS Skin prep, Alginate Adhesive foam (a type of sterile absorbent dressing)
- Left Lower Extremity (LLE): Skin prep, Mepilex (a treated absorbent dressing)

d. 10/27/15 at 4:41 PM: "...L (left) posterior leg, Cleanse c NSS, Skin prep, Impregnate gauze c Hydrogel Abd (dressing), medipore tape"

e. 11/17/15: "Place Medihoney to sacral wound daily"

f. 11/19/15 telephone verbal order: "...Add Alginate c Medihoney to bilateral lower extremities cover c Abd, Kerlix (gauze dressing) Medipore tape daily...(and) PRN if dislodged"

2. Sacral Wound

a. No evidence that the nurse provided sacral wound care on the following dates:
11/2, 11/3, 11/4, 11/5, 11/6, 11/7, 11/8, 11/9, 11/17, 11/30, 12/2, 12/7 and 12/18/15

3. LLE (including calf) wounds:

a. No evidence LLE wound care was provided on:
10/12, 10/20, 10/21, 10/23, 10/24, 10/26, 11/3, 11/4, 11/5, 11/6, 11/7, 11/8, 11/9, 11/10, 11/11, 12/7, 12/12, 12/13 and 12/14/15

b. LLE wound care provided was not in accordance with the physician's order on:11/12, 11/13, 11/14, 11/15 and 11/16/15

4. RLE (including calf) wounds:

a. No evidence that the nurse assessed the RLE wounds between 11/2 - 11/14/15.

b. No evidence of RLE wound care between 11/3 - 11/14/15.

These findings were confirmed by Director of Quality Management A on 5/20/16 between 3:00 PM and 3:40 PM.

II. Based on medical record review, policy review and staff interview, it was determined that for 3 of 4 patients (Patient #'s 1, 2 and 4) in the sample, the nurse failed to perform interventions in accordance with the nursing care plan. Findings include:

The hospital's "Job Description" for the RN documented the following, "...develop a nursing care plan...integrates the medical care plan into the provision of nursing care...Provides nursing care to meet patient's needs...Adheres to established policies and procedures of the hospital..."

The hospital policy entitled "Nursing Care Plan" stated, "...patient has the following characteristic...development of wounds...Each discipline develops a plan of care. Short term goals shall be established...care plans adjusted based on daily assessments...The key issues that Nursing has primary responsibility for...include:...Safety and prevention of in-hospital injury...Mobility plan...Wound prevention and management...Mobility including turns...ROM (range of motion)..."

The hospital policy entitled "Gastric/Duodenal Tube Guidelines: PEG (percutaneous endoscopic gastrostomy), Gastrostomy Tube, Small-bore Nasal Tube, Nasogastric Tube, Orogastric (OG)" stated, "...Nursing...Assess patient every shift for...condition of gastrostomy...insertion site for signs and symptoms of infection or inflammation...stoma care should be performed every shift to prevent breakdown or infection..."

The hospital policy entitled "Guidelines and Protocols, Clinical" stated, "...Bedfast patients turned...every 2 hours..."

A. Patient #1

On 5/19/16 at 9:00 AM, Director of Quality Management A was interviewed and confirmed that Patient #1 required turning every 2 hours and ROM activities to be provided 4 times each day, because the patient was classified as a "Level 1" (complete bedrest and ROM) patient.

Medical record review revealed:

1. 2/3/16 "Progress Notes" documented:
- wound infection around the PEG tube

2. The "24 Hour Patient Record & Plan of Care", dated 2/7, 2/12 and 2/14/16, revealed the following:
- "Goals: Maintain skin integrity. Promote wound healing."
- no evidence that the nurse provided PEG tube care

3. The "24 Hour Patient Record & Plan of Care", dated 2/4 - 2/7, 2/9 - 2/10, 2/20 - 2/21, 2/23, 2/27 - 2/29, 3/3 - 3/7, 3/9, 3/16 - 3/17 and 3/19 - 3/20/16 revealed the following:
- "Mobility Goal: Patient is mobilized safely and reaches their maximal potential."
- ROM QID (four times a day)
- no evidence ROM provided QID

4. No evidence that this bedfast patient was repositioned every 2 hours on the following dates/times:

3/2/16: 3:00 PM - 8:00 PM
3/5/16: 12:00 AM - 6:00 AM
3/13/16: 6:00 PM - 9:00 PM
3/14/16: 3:00 AM - 7:00 AM
3/24/16: 7:00 AM - 10:00 AM

These findings were confirmed by Director of Quality Management A on 5/18/16 between 2:00 PM and 2:35 PM and 3:15 PM to 4:00 PM.

B. Patient #2

Medical record review revealed:

1. The "24 Hour Patient Record & Plan of Care", dated 5/12 - 5/14/16, revealed the following:
- "Goals: Maintain skin integrity. Promote wound healing."
- no evidence that the nurse provided PEG tube care after 8:00 AM on 5/12/16
- no evidence that the nurse provided PEG tube care on 5/13 and 5/14/16

These findings were confirmed by Director of Quality Management A on 5/18/16 at 5:00 PM.

C. Patient #4

Medical record review revealed:

a. 10/8/15 "History and Physical" documented that the patient was admitted on 10/8/15 with:
- ventilator-dependent respiratory failure
- inability to follow commands, squeeze hand or move legs
- PEG tube
- sacral wound and right forearm lesion
- kidney disease requiring ongoing hemodialysis treatments

b. "Skin Breakdown Assessment, The Braden Scale for Predicting Pressure Sore Risk" forms dated 10/12, 10/19 and 10/27/15 rated the patient as "High to Severe Risk" for development of a pressure sore

c. No evidence that the patient was repositioned every 2 hours during the following timeframes:

10/10/15: 3:00 PM - 8:00 PM
10/11/15: 4:00 PM - 8:00 PM
10/15/15: 5:00 PM - 10/16/15 6:00 AM
10/17/15: 8:00 AM - 8:00 PM
10/20/15: 8:00 AM - 3:00 PM
10/23/15: 4:00 AM - 10/24/15 10:00 AM
10/24/15: 10:00 AM - 1:00 PM and 5:00 PM - 9:00 PM
11/7/15: 4:00 AM - 10:00 AM and 1:00 PM - 7:00 PM
11/11/15: 6:00 PM to 11/12/15 6:00 AM
11/18/15: 5:00 PM - 9:00 PM
12/1/15: 3:00 PM - 9:00 PM
12/8/15: 7:00 AM - 8:00 PM

d. No evidence that ROM was provided on the following dates:
10/10 - 10/14, 10/22, 10/29 - 11/3 and 11/6 - 11/16/15

e. No evidence that PEG tube site (stoma) care was performed every shift on the following dates:
10/21, 10/23, 10/26, 10/27, 11/12, 11/26, 11/27, 12/8, 12/9, 12/12, 12/13, 12/15 and 12/20/15

These findings were confirmed by Director of Quality Management A on 5/20/16 at 12:50 PM.

Based on medical record review, policy review and staff interview, it was determined that medical record entries for 3 of 4 patients (Patient #'s 1, 3 and 4) in the sample, failed to be legible, complete, dated and/or timed. Findings include:

The hospital policy entitled "Orders, Physician" stated, "...All physicians' orders...are to be dated and timed..."

The hospital's "Medical Staff Bylaws" stated, "...All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated..."

The hospital policy entitled "Documentation Standards" stated, "...All disciplines...All entries must be legible..."

Medical record review revealed:

A. Patient #1

1. The physician failed to document the date and/or time of the following orders and clinical entries:

a. 2/3/16
- "Admission Orders"
- Authentication of verbal orders for normal saline, blood cultures and chest x-ray
- Authentication of telephone order for antibiotic ointment to PEG site
- "Insulin (subcutaneous) Physician Order Set"
- "Blood Glucose Protocol" order set
- "Wound Progress Note"

b. 2/5/16
- Authentication of verbal order for patient to "go off monitor"
c. 2/11/16
- "Wound Progress Note"
- "Progress Note "

d. 2/13/16
- "Acute Care Progress Note"

e. 2/18/16
- "Wound Progress Note"

3. The "Progress Notes" dated 2/15/16 at 10:32 AM were not legible.

These findings were confirmed by Director of Quality Management A on 5/19/16 at 3:58 PM.

B. Patient #3

1. The following "Progress Notes" entries were not legible:
a. 1/26/16 - 10:20 AM
b. 2/1/16 - 10:02 AM

These findings were confirmed by Director of Quality Management A on 5/20/16 at 4:27 PM.

C. Patient #4

1. 10/8/15 "Admission Orders" - physician failed to enter time of orders

2. 10/8/15 at 3:05 PM "Physician order" for Santyl® ointment - lacked the frequency that the treatment/ointment was to be applied

3. 10/12/15 at 11:00 PM "Telephone Verbal Order": lacked the frequency for the wound care treatments ordered for the right arm, the sacrum, the right lower extremity and the left lower extremity

These findings were confirmed by Director of Quality Management A and Wound Care Registered Nurse A on 5/19/16 at 1:45 PM.

Based on observation, document review and staff interview, it was determined that for 7 of 9 patients (Patient #'s 5, 6, 7, 8, 9, 10 and 11), in the sample observed with indwelling urinary catheters, the infection control officer failed to ensure that staff adhered to infection control measures. Findings include:

The Infection Control/Employee Health Nurse job description stated, "...Plans, organizes, implements, evaluates, and directs the Infection Control Program in accordance with...current CDC (Centers for Disease Control and Prevention) recommendations..."

The CDC Healthcare Infection Control Practices Advisory Committee "Guideline for Prevention of Catheter Associated Urinary Tract Infections 2009" stated, "...Proper Techniques for Urinary Catheter Maintenance...Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor...Empty the collecting bag regularly...and prevent contact of the drainage spigot with the nonsterile collecting container..."

During a hospital tour with Director of Quality Management A and Hospital Administrator A on 5/19/16 between 10:38 AM and 11:19 AM, the following was observed:

A. Patient #'s 5, 6, 7, 8, 9, 10 and 11 had indwelling urinary catheters.

B. Urine collection bags and drainage spigots of Patient #'s 5, 6, 7, 8, 9 and 11 were touching the floor.

C. Patient #10's urine collection bag was laid in a bucket on the floor with spigot in contact with the bucket.

These findings were witnessed and confirmed by Director of Quality Management A and Hospital Administrator A at the time of discovery. In addition, Director of Quality Management A stated on 5/19/16 at 11:19 AM that staff had not followed hospital standards for infection prevention.