HospitalInspections.org

Based on document review and interview, the hospital failed to ensure evaluation of nursing care for assessment and wound documentation of 1 of 10 patients (P1) and hygiene for 9 of 10 patients (P1, P2, P3, P4, P5, P6, P8, P9 and P10 was provided in accordance with policies.

Findings include:

1. Review of policy S05-G, Guidelines and Protocols, Clinical, Revised 01/01/20, indicated the following: To ensure quality patient care, certain standards of care must be upheld. The following table outlines basic tasks and designates the minimum frequency with which these tasks must be performed to maintain quality care.
Assessment: Systematic physical assessment done and recorded on 24 hour flowsheet. Minimum Frequency: Every 12 hours and as condition changes.
Hygiene: Patient bathed/hair combed/shaved. Minimum Frequency: Daily
Hair shampooed: Minimum Frequency: Weekly
Oral care for NPO (nothing by mouth), tube feedings: Minimum Frequency: Every 4 hours
Respiratory: Oral care for vent patients: Minimum Frequency: Every 4 hours and PRN (as needed)
Wounds: Wounds are photographed within 8 hours of admission, 1 day before discharge, weekly as needed. Additionally, on admission and at discharge, all abnormal, non-intact, non-healthy skin will be photographed.

Review of policy WC II-2, Wound Assessment, Revised 01/01/19, indicated the following: Photographs of the wound will be taken...Wound location: The anatomical location should be described. Wound size: The wound is measured in centimeters. Measurement should include length, width, and depth of the wound.

Review of policy WC II-4, Wound Photography, Revised 01/19, indicated the following: Any alteration (abnormal, non-intact, non-healthy skin including bruises...,etc.) in skin integrity should be photographed within 8- hours of admission...

2. Review of medical records (MR) indicated the following:
A. The MR of P1 from hospital A indicated the patient was admitted to the hospital (hospital A) on 7/12/20 and was transferred to acute care hospital B2 on 8/3/20. Nursing assessment documentation indicated the following: On 7/12/20 at 1336 hours (initial assessment): Genitalia: Lesion; Redness; Discharge. Anus/Rectum: Lesions. Gastrointestinal: Abdomen Inspection: Soft; Rounded. Integumentary: "X". Skin Color: Jaundice; Bronze. Skin Integrity: Bruising; Excoriation; Redness; Other (Comment) - open lesions in groin and buttocks. The entry lacked documentation of location of the bruising, excoriation and/or redness.
Wound notes lacked documentation as follows (not all inclusive):
On 7/13/20 at 0930 hours: Wound/Other...Groin/Inguinal Fold: Lacked indication of size/measurements.
On 7/19/20 at 1905 hours: The entry lacked documentation of assessment(s) for Ears or Nose and the Throat - Assessment area was blank. Skin Integrity - Abrasion; Bruising; Excoriation; Rash; Redness (the entry lacked documentation of location or description of the abrasion, bruising, excoriation and/or rash).
On 7/26/20 at 1944 hours: Skin Integrity - Bruising; Excoriation (the entry lacked documentation of location or description of the bruising and/or excoriation).
On 8/1/20 at 2325 hours: Skin Integrity - Bruising (the entry lacked documentation of bruising location or description).
The MR lacked documentation of oral care every 4 hours (per policy) as follows (not all inclusive): From 7/12/20 at 2030 hours to 7/13/20 at 0930 hours. From 7/13/20 at 0930 hours to 7/13/20 at 1910 hours. From 7/13/20 at 1910 hours to 7/14/20 at 1930 hours
The MR lacked documentation of daily bathing (per policy) as follows (not all inclusive): From 7/17/20 at 1743 hours to 7/22/20 at 1604 hours. From 7/22/20 at 1604 hours to 7/24/20 at 1731 hours. From 7/24/20 at 1731 hours to 7/30/20 at 1223 hours. From 7/30/20 at 1223 hours to 8/3/20 at 1400 hours (documented date was 8/6/20).
The MR lacked documentation of weekly hair washes (per policy) as follows: From admission on 7/12/20 at 1336 hours to 7/24/20 at 1731 hours. From 7/24/20 at 1731 hours to 8/3/20 at 1400 hours.
Review of 9 wound photographs (photo/s) lacked description of the wounds. None of the 9 photographs appeared to be of behind the patient's ears. The MR lacked documentation of wounds behind the ears and lacked documentation of nostril wounds present following admission.
B. The MR of P2 lacked documentation of oral care every 4 hours (per policy) as follows (not all inclusive): From 7/13/20 at 2000 hours to 7/18/20 at 1151 hours. From 7/18/20 at 1151 hours to 7/15/20 at 0350 hours. The MR lacked documentation of daily bathing (per policy) as follows (not all inclusive): From 7/22/20 at 1811 hours to 7/26/20 at 1444 hours. The MR lacked documentation of weekly hair washes (per policy) as follows: From admission on 7/13/20 to 7/26/20 at 1444 hours.
C. The MR of P3 lacked documentation of oral care every 4 hours (per policy) as follows (not all inclusive): From 7/15/20 at 2100 to 7/16/20 at 2026 hours. From 7/16/20 at 2026 hours to 7/18/20 at 0237 hours. From 7/18/20 at 0237 hours to 7/21/20 at 1050 hours.
The MR lacked documentation of daily bathing (per policy) as follows (not all inclusive): From 7/14/20 at 2312 hours to 7/18/20 at 1151 hours.
D. The MR of P4 lacked documentation of oral care every 4 hours (per policy) as follows (not all inclusive): From 8/12/20 at 0832 hours (lip moisturizer applied) to 8/13/20 at 1046 hours. From 8/13/20 at 1046 hours to 8/13/20 at 1840 hours. The MR lacked documentation of daily bathing (per policy) as follows (not all inclusive): From 8/11/20 at 0333 hours to 8/14/20 at 0112 hours. From 8/14/20 at 0112 hours to 8/16/20 at 0610 hours. The MR lacked documentation of weekly hair washes (per policy) as follows: From admission on 7/16/20 to 8/6/20 at 0828 hours.
E. The MR of P5 lacked documentation of oral care every 4 hours (per policy) as follows (not all inclusive): From 7/16/20 at 1828 hours to 7/18/20 at 0904 hours. The MR lacked documentation of daily bathing (per policy) as follows (not all inclusive): From admission to 7/18/20 at 0904 hours. The MR lacked documentation of weekly hair washes (per policy) as follows:
F. The MR of P6 lacked documentation of oral care every 4 hours (per policy) as follows (not all inclusive): From admission on 7/24/20 to 7/28/20 at 1831 hours. From 7/28/20 at 1831 hours to 7/30/20 at 1830 hours (lip moisturizer applied). The MR lacked documentation of daily bathing (per policy) as follows (not all inclusive): From 7/24/20 at 2233 hours to 7/29/20 at 1735 hours. The MR lacked documentation of weekly hair washes (per policy) as follows: From admission on 7/24/20 to 8/7/20 at 0858 hours.
G. The MR of P8 lacked documentation of oral care every 4 hours (per policy) as follows (not all inclusive): From 8/14/20 at 1045 hours to 8/17/20 at 1259 hours. The MR lacked documentation of daily bathing (per policy) as follows (not all inclusive): From 8/14/20 at 0111 to 8/16/20 at 0607 hours.
H. The MR of P9 lacked documentation of oral care every 4 hours (per policy) as follows (not all inclusive): From 9/2/20 at 1104 hours to 9/7/20 at 2057 hours. The MR lacked documentation of daily bathing (per policy) as follows (not all inclusive): From 9/2/20 at 1104 hours to 9/6/20 at 2345.
I. The MR of P10 lacked documentation of oral care every 4 hours (per policy) as follows (not all inclusive): From 8/21/20 at 0951 hours to 8/25/20 at 1704 hours. The MR lacked documentation of daily bathing (per policy) as follows (not all inclusive): From admission to 8/23/20 at 0951 hours to 8/26/20 at 1147 hours. The MR lacked documentation of weekly hair washes from admission on 8/20/20 through patient's passing on 9/4/20.

3. On 9/15/20, between approximately 2:00 PM and 4:00 PM, A1, Director of Quality Management/Acting Infection Preventionist Assistant and A2, Chief Nursing Officer, verified the MRs of P1, P2, P3, P4, P5, P6, P8, P9 and P10 lacked documentation of hygiene in accordance with their policy.

Based on document review and interview, the infection preventionist failed to ensure for the development and implementation of hospital-wide infection prevention and control policies and procedures (P&P) based on the facilities capacity that adhered to nationally recognized guidelines for reuse of 2 types of disposable facemasks (N95s and surgical/universal masks) in 1 facility during the COVID-19 pandemic.

Findings include:

1. Review of the policy/procedure titled PPE (personal protective equipment) and Room Guidance During Extended Universal Mask Use, Revised 8/14/2020, indicated the following: The N95 mask may be used by the same employee on a single PUI (patient under investigation) or COVID+patient for up to 7 days. (i.e.1 mask: 1 patient: 1 employee)...The mask is stored in dedicated paper bag, labeled with employee name, patient name and start date.

Review of the facility policy/procedure titled Universal Strategies to Enhance Patient and Staff Safety, Modified 5/27/2020, indicated the following: Universal Mask Use: Universal masks are provided...Masks are issued for use for 3 working days


2. Review of OSHA (Occupational Safety and Health Administration) guidance at https://www.govdocs.com/osha-issues-workplace-guidance-on-wearing-masks/ indicated the following:

Surgical masks:
" Generally cleared as medical devices by the U.S. Food and Drug Administration
" Considered PPE
" Still must be worn correctly to ensure prevention
" Should be disposed of after use

Review of the CDC (Centers for Disease Control) webpage https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html indicated facilities could optimize PPE use (and reuse) during the pandemic according to the following guidelines:

" Conventional capacity: measures consisting of engineering, administrative, and personal protective equipment (PPE) controls that should already be implemented in general infection prevention and control plans in healthcare settings.
" Contingency capacity: measures that may be used temporarily during periods of expected facemask shortages. Contingency capacity strategies should only be implemented after considering and implementing conventional capacity strategies. While current supply may meet the facility's current or anticipated utilization rate, there may be uncertainty if future supply will be adequate and, therefore, contingency capacity strategies may be needed.
" Crisis capacity: strategies that are not commensurate with U.S. standards of care but may need to be considered during periods of known facemask shortages. Crisis capacity strategies should only be implemented after considering and implementing conventional and contingency capacity strategies. Facilities can consider crisis capacity strategies when the supply is not able to meet the facility's current or anticipated utilization rate.

Review of the CDC website for COVID 19 https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html, updated 8/4/2020,
indicates the following:
The outer surface (of the mask), the surface furthest from the wearer's face, presents the highest risk for pathogen transfer to the wearer.
A limited reuse strategy to reduce the risk of self-contamination
One strategy to reduce the risk of contact transfer of pathogens from the FFR (filtering facepiece respirator) to the wearer during FFR reuse is to issue five N95 FFRs to each healthcare staff member who care for patients with suspected or confirmed COVID-19. The healthcare staff member can wear one N95 FFR each day and store it in a breathable paper bag at the end of each shift with a minimum of five days between each N95 FFR use, rotating the use each day between N95 FFRs. This will provide some time for pathogens on it to "die off" during storage [8]. This strategy requires a minimum of five N95 FFRs per staff member, provided that healthcare personnel don, doff, and store them properly each day.
As a caution, healthcare personnel should treat reused FFRs as though they are contaminated.
CDC recommends limiting the number of donnings for an N95 FFR to no more than five per device. It may be possible to don some models of FFRs more than five times.

3. On 9/14/20, between approximately 10:45 AM and 11:00 AM, A1, Director of Quality Management/Acting Infection Preventionist Assistant, and A2, Chief Nursing Officer, indicated the facility had implemented reuse of PPE for surgical masks and N95s. A1 and A2 indicated that surgical masks were kept by staff and reused for 3 days. It was indicated that the surgical masks were stored in brown paper bags at the end of each day and reused for the next two days. A1 and A2 indicated that N95 masks/FFRs (filtering facepiece respirators) were kept and reused for 1 patient/1 staff up to 7 days, at which time they were then sent for reprocessing. A1 further indicated that the same N95 could be used for multiple patients if a surgical mask was worn over the N95. Between approximately 5:00 PM and 5:30 PM, when asked for documentation of nationally recognized guidelines for the facility's determination of facemasks/PPE reuse, A2 indicated that information would be on each policy. A2 indicated he/she would provide that documentation on the next day of survey.

On 9/15/20, between approximately 6:15 PM and 6:30 PM, A7, corporate Infection Preventionist (IP), indicated the corporation orders for 130 hospitals and has stock piles of inventory from which they ship PPE weekly for PAR (periodic automatic replenishment) levels. The IP indicated that once their inventory was caught up from the initial COVID crisis, they decreased reuse of surgical/universal facemasks from 7 days to 3 days. A7 indicated that the corporation has not been able to get enough N95s for this facility. A7 indicated that he/she could not provide documentation of the facility's assessment that determined their current level of capacity for optimizing PPE in accordance with CDC guideline.