HospitalInspections.org

Based on record review and interview, the hospital failed to meet the requirements for the Condition of Participation of Governing Body as evidenced by failing to have a governing body which is effective in carrying out its responsibilities for the conduct of the hospital. This is evidenced by:
1) The Governing Body's failure to ensure the hospital,which is located within a hospital, independently met the requirement for emergency services as evidenced by the hospital utilizing the host hospital's emergency room physicians during "Code" (cardio respiratory arrest) procedures (see findings A-0093).

2) The Governing Body's failure to ensure all physicians providing telemedicine services to the hospital were credentialed and granted appropriate privileges. (see findings A-0052).

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Nursing Services as evidenced by:

1) failure to perform comprehensive wound assessments upon admission, on every shift, and/or as directed per hospital policy/physician order. This deficient practice is evidenced by having no documented evidence of skin/wound assessments and/or wound measurements at the time of admission and/or on every shift for 4 (#6, #12, #14, #19) of 20 current inpatients reviewed for wound care. (see findings tag A-0395).

Based on record review and interview, the hospital failed to ensure all physicians providing telemedicine services to the hospital were credentialed and granted appropriate privileges.

Findings:

Patient #4
Review of Patient #4's medical record revealed an interpretation of a Transthoracic Echocardiography Report dated 10/24/16 by S9MD at Hospital "A".

Patient #17
Review of Patient #17's medical record revealed a CT scan of the head dated 9/18/16 had been interpreted by S14MD at Hospital "A".

Review of the current medical staff roster provided by the hospital revealed S9MD and S14MD were not listed as being credentialed.

In an interview on 11/1/16 at 8:45 a.m. with S1Adm, he verified the above mentioned physicians were not privileged at the hospital. S1Adm said the radiologists at Hospital "A" interpret the hospitals radiology reports. S1Adm also said only the radiology medical director had been privileged to interpret x-rays.

Based on record review and interview, the governing body failed to ensure the hospital,which is located within a hospital, independently met the requirement for emergency services as evidenced by the hospital utilizing the host hospital's emergency room physicians during "Code" (cardio respiratory arrest) procedures.

Findings:

St. Landry Extended Care Hospital is a hospital leasing space on the 2nd floor of Hospital "A" (host hospital).

Review of the Louisiana Hospital Licensing Standards (LAC 48: I. Chapter 93, Section 9305 L-3) revealed:
3. Staff of the hospital within a hospital shall not be co-mingled with the staff of the host hospital for the delivery of services within any given shift.

Review of the current hospital policy titled, Emergency Services, Policy number #: 1-5.11.0, revealed in part: Purpose: To address the management of emergency needs of patients, visitors, passers-by, or staff.
Procedure: In-Patients: Whenever a patient complains of or exhibits an emergency medical condition, the RN on duty shall conduct a screening examination to determine if an emergency condition is present and stabilize the patient's condition within the capability of the personnel present. If necessary, a cardio-pulmonary code will be called. ACLS protocol will be followed until a physician arrives, or is available by phone, to assist with the patient's care. For a co-located hospital, the RN or designee will notify the co-located emergency department and follow directions from the Emergency Physician on duty (Hospital "A" ). If ordered, a staff member will accompany the person to the Emergency Department.

Review of the LTAC hospital's emergency coverage contract revealed the following verbiage:
This emergency coverage agreement (hereinafter referred to as "agreement" ) is made this 1st day of March 2013, by and between LLC-II, LLC d/b/a St. Landry Extended Care Hospital (hereinafter referred to as "LTAC") and Corporation "B" (hereinafter referred to as "Corporation" ).
Whereas, Corporation arranges for the provision of emergency medical services through independent contractor physicians at Hospital "A" ; and
Whereas, LTAC desires to contract with Corporation "B" to provide for the emergency needs of its patients, and Corporation "B" desires to contract with LTAC to provide emergency coverage subject to terms and agreements contained herein, the parties agree hereto as follows:
1. Agreement: a. Corporation will arrange for the physician on duty in the emergency department (hereinafter referred to as "Emergency Physician" ) at Hospital (host Hospital "A" ) to respond to emergency medical situations of LTAC (St. Landry Extended Care Hospital) twenty-four (24) hours per day, seven (7) days per week, fifty-two (52) weeks per year, subject to limitations set forth herein.
b. LTAC acknowledges and agrees that the medical care of the patients in the Emergency Department at Hospital (host Hospital "A" ) are the first priority of the Emergency Physician.

Review of the patient code documentation presented to the survey team by S2DON revealed two patient codes (Patient #9 and Patient #10) had occurred in the LTAC in the last 6 months.

Patient #9
Review of Patient #9's medical record revealed the patient had required cardiopulmonary resuscitation on 9/7/16 at 3:25 a.m. Further review revealed S4MD (ED MD from Hospital "A") had attended the code.

Review of the ED Physician schedule for Host Hospital "A" for 9/6/16 revealed one physician (S4MD) was on duty in the hospital's ED for the 7 p.m. -7 a.m. shift.
.

Patient #10
Review of Patient #10's medical record revealed the patient had required cardiopulmonary resuscitation on 4/24/16 at 9:20 a.m. Further review revealed S3MD (ED MD from Hospital "A" ) had attended the code.

Review of the ED Physician schedule for host Hospital "A" for April 24, 2016 revealed one physician (S3MD) was on duty in the hospital's ED for the 7a.m.-7p.m. shift.


In an interview on 11/1/16 at 9:30 a.m. with S1Adm, he confirmed host Hospital "A" Emergency Department Physicians attended the cardiopulmonary resuscitations in the LTAC. He indicated the ED physicians also pronounced the patients in the LTAC. He confirmed the emergency department physician coverage in host Hospital "A" was one physician for the day shift and one physician for the night shift. S1Adm indicated he had not known Hospital "A" ED physicians could not cover emergencies in the LTAC and provide ED coverage for Hospital "A" concurrently.

In an interview on 11/1/16 at 2:08 p.m. with S5MedDir, he confirmed the hospital (LTAC) did not have physicians on duty at all times. He indicated he wasn't aware that a hospital within a hospital could not share staff.

30984


Based on record review and interviews, the hospital failed to ensure that the registered nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by:

1) failure to ensure each patient was assessed at least every 24 hours by the RN as required by the hospital's policy and the Louisiana State Board of Nurse's Practice Act as evidenced by having patient care provided by LPNs (licensed practical nurses) without documented evidence of an RN assessment at a minimum of every 24 hours for 2 (#4, #15) of 20 (#1-#20) patients' medical records reviewed for RN assessments; and

2) failure to perform comprehensive wound assessments upon admission, on every shift, and as directed per hospital policy. This deficient practice is evidenced by having no documented evidence of skin/wound assessments and/or wound measurements at the time of admission, on every shift, and as directed per hospital policy for 4 (#6, #12, #14, #19) of 20 current inpatients reviewed for wound care.

3) failure to obtain wound treatment orders for a patient (#6) admitted for alteration in skin integrity (pressure wounds) requiring complex wound treatment for 1 (#6) of 20 current inpatients reviewed for wound care.

Findings:

1) Failure to ensure each patient was assessed at least every 24 hours and with a change in condition by the RN as required by the Louisiana State Board of Nurse's (LSBN) Practice Act:

Review of the LSBN's Practice Act revealed that RNs may delegate select nursing interventions to the LPN provided the patient is assessed by an RN every 24 hours.

Review of the hospital policy titled Patient Assessment/Reassessment, Policy Number: 9-12.1.0, revealed in part: Each patient will be assessed by a RN at least once during every 24 hour period. The RN will document the patient's assessment in the medical record. Review of Patient #4's nurse's notes dated 10/20/16 through 10/23/16 revealed LPNs had assessed the patient from the 6:00 p.m. shift of 10/20/16 until the 6:00 p.m. shift on 10/23/16 (72 hours) with no documented evidence of a RN assessment. Review of Patient #4's nurse's notes dated 10/25/16 through 10/27/16 revealed LPNs had assessed the patient from the 6:00 p.m. shift of 10/25/16 until the 6:00 a.m. shift on 10/28/16 (60 hours) with no documented evidence of a RN assessment. Review of Patient #15's nurse's notes dated 10/22/16 and 10/26/16 revealed LPNs had assessed the patient from the 6:00 a.m.- 6:00 p.m. & 6:00 p.m.- 6:00 a.m. on the above dates with no documented evidence of a RN assessment. In an interview on 10/31/16 at 2:05 p.m. with S2DON, she verified a RN should have done an assessment every 24 hours on each patient.


2) Failure to assess patient wounds upon admit, every shift, and as needed thereafter as required by hospital policy.

Review of the hospital policy titled, Staging Pressure Ulcers, Policy #: 9-8.0.1, revealed in part: Policy: Staging of a pressure ulcer is considered an adjunct to an assessment of a pressure ulcer. Pressure ulcers that are present on admit will be staged by a RN or Physical Therapist with wound care training within 8 hours of admission. Pressure ulcers that develop after admission will be staged by a RN or Physical therapist with wound care training.

Procedure: Stage I: intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; it's color may differ from surrounding area.

Stage II: Partial thickness loss of dermis presenting as a shallow, open ulcer with a red, pink
wound bed, without slough. May also present as an intact or open/ruptured serum filled blister.

Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown). and/or eschar (tan, brown, or black) in the wound bed.

Review of the hospital policy titled Patient Assessment/Reassessment, Policy #: 9-1.1.0, revealed in part:
The initial patient assessment is completed within 8 hours of admit. The initial patient assessment performed by nursing will include, but not be limited to, the following information:
Wound Assessment: 1. All wound dressings will be removed and wounds will be visualized, assessed and measured.
2. All pressure ulcers will be staged by a RN within 8 hours of admission.


Patient #6
Review of Patient #6's medical record revealed an Admission date of 10/28/16 with diagnoses including MDR (multi-drug resistant) proteus and MDR acinetobacter, and MRSA (Methicillin-resistant Staphylococcus aureus) Stage IV Sacral wound infection.

Review of Patient #6's Pre-Admission Assessment documentation, dated 10/28/16, revealed in part: Integumentary: Wound: Stage IV Sacral.

Review of Patient #6's Nursing Admission History and Assessment, dated 10/28/16 at 8:40 p.m. revealed in part: Integument: Wounds/Surgical Incisions: box marked," No" was checked. Nutrition/Nutritional screening: Stage III or IV pressure ulcer: box marked," No" was checked. Further review revealed a narrative note entry dated 10/28/16 at 7:35 p.m. indicating dressings to sacral area and bilateral hips were C, D, I (clean, dry, intact). Additional review revealed no documented evidence that the dressings had been removed to assess and measure the wounds.

Review of Patient #6's medical record revealed a Skin Integrity/Wound Identification Form dated 10/28/16 at 9:00 p.m. An entry was noted on the form indicating the patient had 3 wounds. The wounds were identified as follows: Wound #1: Stage IV Sacrum; Wound #2: Stage II: Left Ischium; Wound #3: Stage II: Scrotal base. Further review revealed no wound assessments, no measurements and no further documentation of the stage of the wounds until 3:30 p.m. on 10/31/16 (3 days after patient admission). The wounds were assessed and measured after surveyor's inquiry regarding the lack of assessment and lack of documented measurements of the patient's wounds. Additional review revealed Patient #6's wounds were identified as a Stage IV Sacral wound (Wound #1) and a Stage III Right Ischial wound (Wound #2-progressed from a Stage II to a Stage III) when they were assessed on 10/31/16. The Stage II scrotal wound (Wound #3) was not mentioned on the wound assessment documented on 10/31/16.

In an interview on 10/31/16 at 2:51 p.m. with S13WoundCare, she confirmed Patient #6's wounds had not been measured as of 10/31/16 (prior to surveyor's questions regarding wound assessments and wound measurements). She confirmed the patient's wounds should have been assessed and measured within 8 hours of admission as per hospital policy.

In an interview on 11/1/16 at 12:41 p.m. with S2DON, she confirmed Patient #6's Pre-Admission Assessment had indicated the patient had a Stage IV Sacral Pressure Wound. S2DON also confirmed, after review of Patient #6's medical record, that the initial nursing assessment had indicated Patient #6 had no wounds. S2DON indicated the wound information documented on the Skin Integrity/Wound Identification Form dated 10/28/16 at 9:00 p.m. had been obtained and transcribed from the transferring hospital's notes because according to the admit nurse's documentation she had not removed the dressings to assess Patient #6's wounds. S2DON further indicated the Stage II scrotal wound (Wound #3) was not mentioned in the wound assessments documented on 10/31/16. S2DON confirmed it was policy to remove wound dressings in order to assess and document the appearance of wounds and to obtain baseline wound measurements on admit.

In an interview on 11/1/16 at 2:08 p.m. with S5MedDir, he indicated if it is hospital policy that the RN was to assess and measure wounds then they are expected to follow that policy. He indicated if RNs are not following the policy then that issue needs to be corrected.


Patient #12
Review of Patient #12's medical record revealed a document titled Skin Integrity/Wound Identification Form dated 10/29/16 (date of admission). Further review revealed wound #1 was listed as a Stage II to the coccyx, but there were no measurements as of 10/31/16. Wound number 2 was documented as Left sacrum, but was not staged or measured as of 10/31/16.

In an interview on 10/31/16 at 3:02 p.m. with S13WoundCare, she said patient's wounds should have been measured within 8 hours of admission.

Patient # 14
Review of Patient #14's medical record revealed she was admitted to the hospital on 10/19/16 with Bilateral feet neuropathetic ulcers, Right ankle wound, Pneumonitis, and Anemia.

Review of Patient #14's Skin Integrity Wound Identification Form revealed 3 wounds (#1 right ankle, #2 right foot plantar, and #3 left foot plantar) with no documented evidence that the wounds were staged or measured upon admission. Further review of the Pressure Ulcer Wound Assessment Form revealed assessment on 10/19, 10/26, and 10/27/16 with no documented evidence that the wounds had been staged or measured.

Review of Patient #14's Progress noted revealed that on 10/28/16, the physician notes read in part: "R ankle stage 3 pressure injury plantar R & L unstageable pressure injury."

In an interview on 10/31/16 at 4:15 p.m., S7ADON confirmed after review of the wound assessment sheets and nurses' notes that the nurses failed to stage Patient #14's wounds. She also confirmed after review of the progress notes that the only documentation of staging of the wounds was on 10/28/16 by the patient's primary care physician.

Patient #19Review of Patient #19's medical record revealed the patient had been admitted to the hospital on 10/27/16 with diagnosis which included a right hip fracture with open reduction and internal fixation and a Stage III ulcer to the right hip.Review of Patient #19's medical record revealed a document titled Skin Integrity/Wound Identification Form dated 10/27/16. Further review revealed 3 wounds had been identified: A Stage II ulcer to the coccyx, a Stage II wound to the right heel and an unstageable wound to the left heel. Further review revealed as of 11/1/16, there had been no measurements taken of the wounds. In an interview on 11/1/16 at 10:40 a.m. with S13WoundCare, she verified Patient #19's wounds had not been measured.

3) failure to obtain wound treatment orders for a patient (#6) admitted for alteration in skin integrity (pressure wounds) requiring complex wound treatment.

Review of Patient #6's Pre-Admission Assessment documentation, dated 10/28/16, revealed in part: Integumentary: Wound: Stage IV Sacral; Admission Criteria: Primary: Wound/Skin; Actively treated Co-morbid conditions: Alteration in Skin Integrity requiring complex wound care; Functional Impairment; and Wound.

Review of Patient #6's medical record revealed a Skin Integrity/Wound Identification Form dated 10/28/16 at 9:00 p.m. An entry was noted on the form indicating the patient had 3 wounds. The wounds were identified as follows: Wound #1: Stage IV Sacrum; Wound #2: Stage II: Left Ischium; Wound #3: Stage II: Scrotal base.

Review of Patient #6's Admission orders, dated 10/28/16 at 11:00 p.m., revealed no documented evidence that wound care orders had been written. Further review of the patient's MD orders from 10/29/16-10/31/16 (prior to 3:30 p.m.) revealed no documented evidence that wound care orders had been obtained. At the time of the record review on 10/31/16 Patient #6 had been an inpatient at the hospital for 3 1/2 days and had not received treatment for the wounds documented on 10/28/16 at 9:00 p.m. (admission).

In an interview on 10/31/16 at 2:51 p.m. with S13WoundCare, she confirmed, after review of Patient #6's medical record, that no wound care orders had been obtained to treat the patient's wounds and no treatments had been performed.
In an interview on 11/1/16 at 2:08 p.m. with S5MedDir, he indicated the hospital's process was to carry over previous wound care orders from the transferring hospital. He indicated the admitting nurse calls the admitting physician and writes the wound care orders as verbal orders.


31206

30984


Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept current individualized and comprehensive nursing care plans for each patient for 6 (#2, #5, #6, #14, #16, #24) of 6 sampled patients reviewed for care planning out of a total sample of 30 patient records reviewed.

Findings:

Review of the hospital policy titled, The Nursing Process- Care Planning, Policy number #: 9-1.2.0, revealed in part:
Purpose: To provide each patient with an individualized plan of nursing care; To assist nursing staff in determining priorities; To aid nursing staff in performing nursing activities in a goal directed manner; To provide for continuity of care, goal setting and discharge planning; To assist nursing staff in documenting nursing interventions and evaluations appropriately in the patient's chart.
Policy: Nursing Plan of Care: The nursing plan of care provides a collaborative /systematic method of individualized care that focuses on the patient's response to an actual or potential alteration in health based patient assessment. This plan reflects all disciplines involved in providing care to the patient. It communicates pertinent patient problems/needs, delineates appropriate medical and nursing interventions to meet these needs, and documents the effectiveness of those interventions in the medical record.
Procedure: Nurse responsibility: All patients shall be assessed on admission and a written plan of care developed and initiated within 24 hours of admission by a RN. The plan of care shall reflect those standards of care applicable to that individual.
Patient Problems/Needs/Interventions/Effectiveness: The nursing plan of care shall be evident in the medical record , providing evidence of the patient's problems/needs with the interventions to meet these needs as well as their effectiveness documented.
Plan of Care Review and Update: The patient's plan of care shall be reviewed at least weekly by a RN or LPN. The plan of care will be updated by a RN or LPN as needed as a result of ongoing assessment and interdisciplinary rounds.
Patient #2Review of the medical record for Patient #2 revealed an admission date of 10/27/16 with admission diagnoses including Hypertension, Pneumonia and Chronic Obstructive Pulmonary Disease. Further review revealed the patient was receiving nutrition via PEG (percutaneous endoscopic gastrostomy) tube feedings. Review of the care plan for Patient #2 revealed altered nutrition (nutrition via PEG tube feedings) and Hypertension were not addressed as identified problems on the plan of care. The care plan was not specific and not individualized to the patient's care/needs.In an interview on 11/1/16 at 2:20 p.m. with S2DON, she agreed all medical diagnoses that the patient was receiving treatment for should have been addressed in the plan of care. She also agreed the care plans should have been individualized to meet the needs of the patient.Patient #5 Review of the medical record for Patient #5 revealed an admission date of 10/4/16 with diagnoses including Diabetes Mellitus Type II. Review of the care plan for Patient #5 revealed the problem Alteration in Nutrition, less than body requirements related to Diabetes was left blank. The care plan was not specific and not individualized to the patient's care/needs. In an interview on 11/1/16 at 2:20 p.m. with S2DON, she agreed Diabetes should have been identified as a problem on Patient #5's plan of care. Patient #6Review of the medical record for Patient #6 revealed an admission date of 10/28/16 with admission diagnoses including wounds infected with multidrug resistant bacteria. Review of the plan of care revealed the patient's infected wounds had not been addressed as identified problems on the care plan. The care plan was not specific and not individualized to the patient's care/needs. An interview was conducted with S2DON on 11/1/16 at 2:20 p.m. She reported the patient's care plan should have identified wounds infected with multidrug resistant bacteria as current problems on the plan of care. Patient #14Review of Patient #14's medical record revealed she was admitted to the hospital on 10/19/16 with admitting diagnoses of Bilateral feet neuropathetic ulcers, Right ankle wound, Pneumonitis, and Anemia. Review of Patient #14's progress note revealed that on 10/28/16, the physician notes read in part: "R (right) ankle stage 3 pressure injury plantar R & L (left) untraceable pressure injury." Review of the plan of care revealed the patient's right ankle stage III pressure injury and plantar right and left unstageable pressure injury were not identified as problems on the care plan. The care plan was not specific and not individualized to the patient's care/needs. In an interview on 10/31/16 at 4:15 p.m., S7ADON confirmed after review of the wound assessment sheets and nurses' notes that the nurses failed to stage Patient #14's wounds. She also confirmed after review of the progress notes that the only documentation of staging of the wounds was on 10/28/16 by the patient's primary care physician.Patient #16Review of the medical record for Patient #16 revealed an admission date of 10/12/16 with admission diagnoses including HTN (high blood pressure). Review of the plan of care revealed the patient's hypertension had not been addressed as an identified problems on the care plan. The care plan was not specific and not individualized to the patient's care/needs.

Patient #24
Review of Patient #24's current plan of care revealed Nursing diagnoses were checked with no goals and/or interventions included. The care plan was not specific and not individualized to the patient's care/ needs.

An interview was conducted with S2DON on 11/1/16 at 2:20 p.m. She reported the patient's care plan should have identified wounds infected with multidrug resistant bacteria as current problems on the plan of care. S2DON confirmed after review of the above plan of cares that the nursing staff failed to address current medical problems and /or patient issues, and failed to have goals and interventions on all problems identified.







31206

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with the orders of the practitioner responsible for the patient's care. This deficient practice is evidenced by failure of the nursing staff to administer patient medications as ordered for 1 (#16) of 8 (#3, #7, #11, #13, #14, #15, #16, #21) patients reviewed for medication administration out of a total sample of 30.

Findings:Review of Patient #16's medical record revealed she was admitted to the hospital on 10/12/16 with admitting diagnoses that included hypertension (elevated blood pressure). Further review revealed an order for Clonidine 0.1 mg prn Q 4 hours for SBP > 160 or DBP > 90. On 10/13/16 at 6:00 p.m., an order was noted for HydrAlazine 10 mg IV every 2 hours as needed for SBP>160.

Review of Patient #16's medication administration record revealed the following:
10/19/16 at 9:00 a.m. B/P 181/93
10/22/16 at 9:00 a.m. B/P 164/91; and at 9:00 p.m. 171/93.
10/30/16 at 9:00 p.m. B/P 178/88
Further review of Patient #16's medication administration record revealed the as needed Clonidine and/or HydrAlazine dose was not administered as ordered per parameters for elevated SBP and/or DBP.

Review of Patient #16's nurses notes revealed no documented explanation for not administering the Clonidine and/or HydrAlazine as ordered on the above referenced dates.

In an interview on 11/01/16 at 11:10 a.m., S6RN confirmed after review of Patient #16's medical record (MARs & Nurses' Notes) that there was no documentation of administration of Clonidine and/or HydrAlazine and no explanation for the failure to administer as ordered for blood pressures that fell outside of the ordered parameters.

30984

Based on record reviews, observation and interviews, the hospital failed to ensure the infection control officer implemented a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:
1) failure to ensure hand hygiene was performed before and after glove changes (during a wound dressing change) and failure to ensure a patient's (#7) bedside table was disinfected before and after use during a wound dressing change for 1 (#7) of 1 patients observed for a wound dressing change; and
2) failure to ensure proper positioning of patient catheter bags to reduce the risk of urinary tract infections as evidenced by catheter bags touching/dragging the floor and/or having dependent loops for 1 (#22) of 1 patients observed with an indwelling Foley catheter; and
3) failure to ensure the nursing staff wore clean gloves when touching a patient for 1 (S12LPN) of 6 staff members observed providing patient care.
Findings:
1) Failure to ensure hand hygiene was performed before and after glove changes and failure to ensure the Patient's (#7) bedside table was disinfected before and after use during a wound dressing change.
Review of the hospital policy titled, Hand Hygiene, Policy #: 8-5.0.0, revealed in part:
Policy: Handwashing will be performed with soap and water to remove dirt, organic material and transient microorganisms. Hand Antisepsis will be performed with an alcohol-containing antiseptic hand rub to remove or destroy transient microorganisms when hands are already clean (not soiled with dirt or organic material). Procedure: Decontaminate hands: after removing gloves.
On 11/2/16 at 11:00 a.m., an observation was made of S13WoundCare performing a wound dressing change on Patient #7. S13WoundCare was observed placing the wound dressing supplies on the patient's bedside table. S13WoundCare failed to disinfect the surface of the bedside table prior to placing the wound care supplies on the table. S13WoundCare was observed changing her gloves during the procedure. She failed to perform hand hygiene after the glove change. Upon completion of the dressing change, she removed her gloves and picked up the empty dressing supply packages from the table. S13WoundCare did not perform hand hygiene after glove removal, prior to exiting Patient #7's room, she was observed touching the patient's door handle upon exit from the room. S13WoundCare failed to disinfect the bedside table after completion of the procedure.
In an interview on 11/2/16 at 11:30 a.m. with S2DON, she confirmed it was her expectation that staff would perform hand hygiene before and after glove changes. She agreed the bedside table should have been disinfected before and after the dressing change procedure. S2DON reported hand sanitizer was readily available to staff and indicated dispensers were located inside the patient rooms as well as in the hallways.2) Failure to ensure proper positioning of patient catheter bags to reduce the risk of urinary tract infections as evidenced by a catheter bag touching the floor and having dependent loops.On 11/2/16 at 10:25 a.m. an observation was made of Patient #22. He was positioned with the head of his bed slightly elevated. Patient #22's catheter bag, approximately half full, was touching the floor and was positioned with a dependent loop.
In an interview on 11/2/16 at 11:20 a.m. with S2DON, she confirmed the above referenced observations. She also confirmed catheter bags should not be positioned with dependent loops or touching the floor. 3) Failure to ensure the nursing staff wore clean gloves when touching a patient.
In an observation on 10/31/16 at 1:45 p.m., S12LPN walked into Patient #8's room to assist with changing his brief and perform a wound assessment. She donned one of her gloves and dropped the other glove on the floor. She then picked the glove up off of the floor and donned it on her left hand. S12LPN then assisted with patient care.In an interview on 11/2/16 at 1:46 p.m. with S2DON, she verified S12LPN should not have worn the glove that had fallen on the floor while providing patient care.