HospitalInspections.org

Based on review of medical records (MR), facility policies and procedures and staff interviews, it was determined staff failed to:

a) Perform and document ordered wound care.

b) Perform and document daily blood sugars as ordered and administer the ordered amount of insulin.

c) Perform PICC (peripherally inserted central catheter) line care according to the facility's policy.

d) Administer medications and skin treatments as ordered by the Medical Doctor.

e) Assess and document chest tube drainage and site assessment.

f) Ensure patients were turned every 2 hours as ordered.

g) Ensure each patient's Plan of Care was completed and up to date to meet the patient's needs.

h) Ensure the licensed nurse assessed the effectiveness of pain relief interventions.

i) Ensure the blood product was given within 30 minutes from obtaining from the blood bank.

j) Total Parenteral Nutrition solution was changed every 24 hours.

k) Dobutamine drip was accurately monitored and documented.

This affected 5 of 5 MR's reviewed and did affect MR # 1, MR # 5, MR # 2, MR # 6, MR # 3, and had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to A 392, A 396, A 405 and A 409 for findings.

Based on review of medical records (MR), facility policies and procedures and staff interviews, it was determined staff failed to:

a) Perform and document ordered wound care.

b) Perform and document daily blood sugars as ordered and administer the ordered amount of insulin.

c) Perform PICC (peripherally inserted central catheter) line care according to facility policy.

d) Administer medications and skin treatments as ordered by the MD (Medical Doctor).

e) Assess and document chest tube drainage and site assessment.

f) Ensure patients were turned every 2 hours as ordered.

This affected 5 of 5 MR's reviewed and did affect MR # 6, MR # 1, MR # 5, MR # 2, MR # 3, and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Pressure Ulcers, Wound Assessment and Staging
Policy Number: 20-03055
Effective Date: 10/1/14

Performing a wound assessment including staging of a wound and making determination as to whether wounds are present on admission to a healthcare facility constitutes a practice beyond the basic educational preparation of the Registered Nurse (RN) and /or the Licensed Practical Nurse (LPN) as identified by the Alabama Board of Nursing...

1. The wound nurse will see all wound patients for an initial and weekly assessment of all wound and staging of pressure ulcers...

2. In the absence of the wound nurse, a certified RN and / or LPN can assess wounds, stage pressure ulcers and determine as to whether wounds are present on admission. The assessment can be optional but documentation will include, at minimum, the following:

a. Wound location
b. Description of wound bed
c. Drainage (if any)
d. Type of wound
e. Stage (if pressure ulcer)
f. Measurements

Policy: Peripherally Inserted Central Catheters (PICC) and Midline Catheters
Policy #: 20-03048
Effective Date: 10/01/14

Purpose: PICC and Midline Catheters are intended to provide longer term intravenous access for blood drawing, for intravenous fluids and medication administration or for patients in whom peripheral intravenous access has been unsuccessful.

III. PICC and Midline - Site Care and Dressing Change

Dressing should be routinely changed at least every 7 days along with injection caps and Curos caps.

11. Clean the skin around the catheter exit site with Chloraprep swab. Use a back and forth Friction scrub for 30 seconds...

15. Wipe skin with protective prep pad in a square approximately the size of the transparent dressing edges where Statlock will be applied and secure Statlock and allow to air dry.

16. Apply transparent dressing over catheter, making sure dressing is secure...

18. Document procedure and condition of site in the appropriate area.

1. MR # 6 was admitted to the facility on 2/23/16 with Diagnoses including Congestive Heart Failure, Coronary Artery Disease, Status Post Bypass Times 4, Mitral Valve Regurgitation with Mitral Valve Repair and Continued Dobutamine (used to treat acute but potentially reversible heart failure) Therapy.

Review of the physician's orders dated 2/23/16 at 1:50 PM revealed orders for Santyl topical daily. There was no documentation where the Santyl was to be applied.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 2/24/16 revealed the nurse documented at 12:00 PM the wound bed was not open, surrounding skin was intact, and no drainage. The nurse also documented that wound care was provided at 12:00 pm. There was no documentation what wound care was provided.

Further review of the Nurse's 24 Hour Assessment and Progress Record dated 2/24/16 revealed no documentation the dressing to the sacral wound was dry and intact after 12:00 PM to 10:00 PM.

Review of the wound nurse assessment dated 2/24/16 at 1:21 PM revealed the patient had an unstageable wound to the sacrum that measured 14 cm long, 13 cm wide, and 0.2 cm deep. There was minimal serous drainage. The wound nurse documented the physician was notified on 2/23/16.

Further review of the wound nurse assessment dated 2/24/16 at 1:21 PM revealed, "...(patient) has an unstageable sacral wound that is slough covered with darkly discolored periwound. There are 2 small open lesions noted on ...(patient)...rt. (right) buttocks that are granulating well that could be friction wounds. There is a minimal amount of serous drainage noted from the site, and no foul odor is appreciated. Patient...(child)...is in the room and aware of pressure wound. Area was well cleansed with wound cleanser, Elta and moisture barrier applied to site and covered with abd and tape..."

Review of the physician orders dated 2/24/16 at 2:30 PM revealed the following, Cleanse sacral area with NS BID (twice a day), apply Medihoney alginate dressing and cover with NS lightly dampened gauze and abd.

Review of the Nurse's 24 Hour Assessment and Progress Records dated 2/25/16 and 2/26/16 revealed no documentation of a wound assessment.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 2/25/16, 2/26/16, 2/27/16, 2/28/16 and 2/29/16 revealed no documentation the dressing to the sacral wound was dry and intact between 2/24/16 at 6:00 PM to 2/29/16 at 2:00 PM.

Further review of the Nurse's 24 Hour Assessment and Progress Record dated 2/27/16 revealed documentation the wound bed was pink with the surrounding skin being intact and moderate amount of drainage. There was no documentation of the color of the drainage.

Further review of the Nurse's 24 Hour Assessment and Progress Record dated 2/28/16 revealed documentation by the 7:00 AM to 7:00 PM nurse the wound bed was pink with the surrounding skin being intact and small amount of drainage. There was no documentation of the color of the drainage.

Further review of the Nurse's 24 Hour Assessment and Progress Record dated 2/28/16 revealed documentation by the 7:00 PM to 7:00 AM nurse at 10:30 PM included, "Dressing to sacral area changed. Noted 3 areas of breakdown 100% yellow wound bed slough to inner sacral area. Left buttocks w/ (with) stage 2 breakdown shearing w/ slight bleeding. Separate ulcerated area to L (left) buttock w/ slough and eschar unstageable...no incontinence used urinal". There was no documentation the physician or the wound nurse was notified of the wound deterioration.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 2/29/16 revealed the wound bed was red and yellow, the surrounding skin was red, and a small amount of drainage. There was no documentation of the color of the drainage.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 3/1/16, 3/2/16 and 3/3/16 revealed no documentation of a wound assessment. There was no documentation the dressing to the sacral area was dry and intact between 3/1/16 at 6:00 PM to 3/3/16 at 8:00 AM.

Further review of the Nurse's 24 Hour Assessment and Progress Record dated 3/2/16 revealed the wound bed was red and yellow, the surrounding skin was red, and there was no drainage. There was no documentation of the color of the drainage.

Further review of the Nurse's 24 Hour Assessment and Progress Record dated 3/2/16 revealed documentation there was Mepilex on the patient's hand. There was no documentation of an assessment of the patient's hand nor documentation of a physician's order to apply the Mepilex to the patient's hand.

Review of the wound nurse documentation dated 3/3/16 revealed the sacral wound measured 14 cm long, 13 cm wide and 0.2 cm deep. The wound to the sacrum was unstageable with a reduced amount of slough and increased amount of granulation tissue. There was no documentation of the wound description noted in the Nurse's 24 Hour Assessment and Progress Record dated 2/28/16.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 3/5/16 and 3/6/16 revealed the wound to the sacral area had a pink and red wound bed, the surrounding skin was intact with a small amount of drainage. There was no documentation of the color of the drainage.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 3/6/16 and 3/7/16 revealed no documentation the dressing to the sacral area was dry and intact between 6:00 PM and 3/7/16 at 8:00 AM.

Further review of the Nurse's 24 Hour Assessment and Progress Record dated 3/7/16 revealed no documentation of a wound assessment and at 4:00 AM 3/8/16, "Incontinent, cleaned up and turned..." at 6:30 AM, "Patient bathed and cleaned for incontinent episode." There was no documentation if the sacral wound dressing had been changed.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 3/8/16 and 3/9/16 revealed no documentation of a wound assessment. There was no documentation if the dressing to the sacral wound was dry and intact between 4:00 PM to 3/9/16 at 8:00 AM.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 3/9/16, 3/10/16 and 3/11/16 revealed no documentation of a wound assessment. There was no documentation if the dressing to the sacral wound was dry and intact between 8:00 AM to 3/11/16 at 9:00 PM.

Further review of the Nurse's 24 Hour Assessment and Progress Record dated 3/10/16 revealed no documentation of a wound assessment. At 10:00 PM the nurse documented the patient voids with a urinal and mild spillage.

Further review of the physician's orders dated 3/11/16 at 9:50 AM revealed documentation of a consult to another physician for possible wound debridement.

Review of the wound nurse's assessment dated 3/11/16 at 11:04 AM revealed the wound to the sacral area now measured 14 cm long, 13 cm wide, and 4 cm deep with an additional small area to the left buttocks (this area was first identified on 2/28/16). There was undermining at 9 o'clock which was 4 cm deep and at 12 o'clock which measured 0.5 cm deep. There was tunneling at 11 o'clock which measured 9 cm deep.

Review of the physician's order dated 3/11/16 revealed a change in wound care as follows: cleanse sacral wound with wound cleanser, pack with NS soaked gauze, cover with an abd pad and tape. Right to left turns strict every 2 hours. Change dressing BID.

Further review of the Nurse's 24 Hour Assessment and Progress Record dated 3/11/16 revealed documentation at 9:30 PM the patient had an incontinent episode of loose bowel movement. the patient was cleaned and wound care was provided. Then at 12:00 AM 3/12/16 the patient was incontinent of urine and pericare was provided.

Review of the physician's order dated 3/12/16 at 9:45 AM revealed orders for Vancomycin 1 gram IV now and start Zosyn 3.375 grams IV every 8 hours.

Review of the MAR revealed no documentation the nursing staff applied Santyl on 2/25/16, 2/26/16, 2/27/16, 2/28/16, 2/29/16, 3/4/16, 3/8/16, 3/9/16, 3/10/16, and 3/11/16.

Review of the physician's orders dated 3/12/16 at 10:15 AM revealed an increase in Oxycodone from 5 mg to 7.5 mg every 4 hours as needed for moderate pain.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 3/12/16 revealed the patient was transferred to the hospital.

Review of the hospital's History and Physical for the admission dated 3/12/16 revealed the following, "...the patient developed sacral decubitus ulcer due to immobility and overweight and lying at bed for too long..."

Review of the Operative Report dated 3/14/16 revealed a debridement of 4 or 41/2 inch by 5 inch subcutaneous pocket of the decubitus ulcer.

An interview was conducted on 3/30/16 at 2:15 PM with EI # 4, Registered Nurse who documented the 2/28/16 wound description at 10:30 PM. The surveyor asked who she reported the wound deterioration to and the response was my Charge Nurse.

An interview was conducted on 3/31/16 at 9:15 AM with EI # 5, Charge Nurse. The surveyor asked if EI # 4 reported the wound deterioration on MR # 6. The response was, "yes". The surveyor then asked who EI # 5 reported the wound deterioration to and the response was, "I drop the ball on that one".

Turn Every Two Hours:

Review of the physician's order dated 2/24/16 revealed orders to turn right to left every two hours.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 2/23/16 revealed no documentation the patient was turned every two hours between 8:00 AM and 8:00 PM.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 2/26/16 revealed no documentation the patient was turned every two hours between 12:00 PM and 8:00 PM. The nurse documented at 6:00 PM the patient had been up to the chair for 2 hours that day. There was no documentation what two hours the patient was up in the chair.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 2/28/16 and 3/2/16 revealed documentation the patient was up to the chair from 10:00 AM to 4:00 PM, which was 6 hours.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 3/4/16 revealed documentation the patient was up to the chair from 8:00 AM to 12:00 PM, which was 4 hours. There was no documentation the patient was turned every two hours between 12:00 PM to 8:00 PM, which was 8 hours.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 3/6/16 revealed documentation the patient was up to the chair from 10:00 AM on 3/6/16 to 6:00 AM on 3/7/16, which was 20 hours.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 3/9/16 revealed no documentation the patient was turned every two hours between 4:00 PM to 8:00 PM, which was 4 hours.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 3/10/16 revealed documentation the patient was up to the chair from 7:00 AM to 7:00 PM, which was 12 hours.

CVL:

Review of the Nurse's 24 Hour Assessment and Progress Record dated 2/23/16 at 2:00 PM revealed the following, "right (upper) arm PICC intact", which is in the right arm.

Review of the physician's orders dated 2/23/16 at 2:15 PM revealed the IV access was a, "central line Subclavian", which is in the right chest.

Further review of the Nurse's 24 Hour Assessment and Progress Records dated 2/23/16 revealed the nursing staff cleaned the CVL site with Chlorhexidine every 2 hours between 2:00 PM to 6:00 AM on 2/24/16.

Review of the Nurse's 24 Hour Assessment and Progress Records dated 2/24/16 and 2/25/16 revealed no documentation the CVL was held in place by the Statlock between 7:00 AM to 2/25/16 AT 8:00 AM.

Further review of the Nurse's 24 Hour Assessment and Progress Record dated 2/25/16 revealed the nursing staff cleansed the CVL site with Chlorhexidine every 2 hours between 8:00 AM to 6:00 PM.

Review of the Nurse's 24 Hour Assessment and Progress Records dated 2/25/16, 2/26/16 and 2/27/16 revealed no documentation the catheter was held in place by the Statlock between 6:00 PM and 8:00 AM on 2/27/16.

Further review of the Nurse's 24 Hour Assessment and Progress Record dated 2/26/16 at 8:00 AM revealed there was a 3 lumen catheter to the right Subclavian, "two of the three lumens were working and the 3rd lumen had no tubing connected and no connection to the lure lock, just the catheter bare". The nurse applied a slide lock to the catheter and notified the physician. There were no new orders obtained.

Review of the physician's orders dated 2/26/16 (Friday) at 1:50 PM revealed an order to consult a physician for replacement of Subclavian on Monday.

Review of the physician's order dated 2/27/16 at 11:43 AM revealed an order for a chest X-ray status post a CVL.

Review of the Nurse's 24 Hour Assessment and Progress Records dated 2/27/16, 2/28/16 and 2/29/16 revealed the nursing staff cleansed the CVL site with Chlorhexidine at 8:00 AM. There was no documentation the catheter was held in place by the Statlock between 10:00 AM to 8:00 AM on 2/29/16.

Further review of the Nurse's 24 Hour Assessment and Progress Record dated 2/27/16 revealed the nurse changed the CVL dressing at 8:00 AM and 10:00 AM.

Review of the Nurse's 24 Hour Assessment and Progress Records dated 2/29/16 and 3/1/16 revealed the nursing staff cleansed the CVL site with Chlorhexidine every 2 hours between 8:00 AM to 6:00 PM. There was no documentation the CVL was held in place by the Statlock between 6:00 PM and 8:00 AM on 3/1/16.

Review of the Nurse's 24 Hour Assessment and Progress Records dated 3/1/16 and 3/2/16 revealed the nursing staff cleansed the CVL site with Chlorhexidine every two hours between 8:00 AM and 6:00 AM on 3/2/16.

Further review of the Nurse's 24 Hour Assessment and Progress Record dated 3/1/16 revealed the nurse changed the dressing on the CVL every 2 hours between 8:00 AM and 6:00 AM on 3/2/16.

Review of the Nurse's 24 Hour Assessment and Progress Records dated 3/5/16, 3/6/16 and 3/7/16 revealed the nursing staff cleansed the CVL site with Chlorhexidine every two hours between 8:00 AM and 6:00 PM on 3/7/16.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 3/8/16 revealed the nurse changed the dressing on the CVL every 2 hours between 8:00 AM and 6:00 AM on 3/9/16.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 3/9/16 revealed the nursing staff cleansed the CVL site with Chlorhexidine every two hours between 8:00 AM and 4:00 PM.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 3/10/16 revealed the nursing staff cleansed the CVL site with Chlorhexidine every two hours between 7:00 AM and 7:00 PM.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 3/11/16 revealed no documentation the catheter was held in place by the Statlock.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 3/12/16 revealed the nursing staff cleansed the CVL site with Chlorhexidine every two hours between 8:00 AM and 6:00 PM.

An interview was conducted on 3/31/16 at 8:20 AM with EI # 1 who verified the above documentation.

Administration of Insulin:

Review of the physician's order dated 2/23/16 at 12:35 PM revealed the following sliding scale for Regular Insulin:

BG (blood glucose) 0 to 170 mg (milligrams)/dl (deciliter) = 0 units SQ (subcutaneous).

BG 171- 200 mg/dl = 2 units SQ
BG 201 - 250 mg/dl = 4 units SQ
BG 251 - 300 mg/dl = 6 units SQ
BG 301 - 350 mg/dl = 8 units SQ
BG 351 - 400 mg/dl = 10 units SQ
BG 401 mg/dl or above 14 units SQ and call the physician.

Review of the Diabetic Flowsheet revealed the following:

2/24/16 at 9:00 PM- BG was 179 and the nurse administered 4 units of insulin instead of the 2 that was ordered.

2/17/16 at 4:00 PM - BG was 191 and the nurse administered 4 units of insulin instead of the 2 that was ordered.

3/3/16 at 11:00 AM - BG was 185 and the nurse administered no insulin instead of the 2 that was ordered.

3/4/16 at 6:00 AM - BG was 172 and the nurse administered no insulin instead of the 2 that was ordered.

3/5/16 at 11:00 AM - BG was 183 and the amount of insulin the nurse administered was illegible.

3/7/16 at 11:00 AM - BG was 198 and the nurse administered 4 units of insulin instead of the 2 that was ordered.

3/9/16 at 11:00 AM - BG was 241 and the nurse administered 8 units of insulin instead of the 4 that was ordered.

3/10/16 at 11:00 AM - BG was 284 and the nurse administered 8 units of insulin instead of the 6 that was ordered.

3/11/16 at 11:00 AM - BG was 188 and the nurse administered no insulin instead of the 2 that was ordered.

3/11/16 at 9:00 PM - BG was 173 and the nurse administered no insulin instead of the 2 that was ordered.

3/12/16 at 11:00 AM - BG was 188 and the nurse administered 4 units of insulin instead of the 2 that was ordered.

An interview was conducted on 3/31/16 at 8:20 AM with EI # 1, who verified the above findings.

2. MR # 1 was admitted to the facility on 3/25/16 with an admitting diagnosis of Sepsis, Respiratory Failure, Infective Stage 4 Sacral Ulcer, VRE ( Vancomycin Resistant Enterococcus), E.coli (Escherichia coli) and UTI (Urinary Tract Infection).

Review of the physician order dated 3/26/16 revealed the following, "... Wound care..."

Review of the nurse note dated 3/26/16 under the daily wound section and interventions revealed this section was blank. Review of the narrative section revealed the nurse documented the dressing was dry and intact.

Further review of the 3/26/16 nurse note revealed no documentation of a dressing change on either shift by the nurse and no documentation the physician order dated 3/26/16 was clarified with the physician for specific wound care orders.

Review of the nurse note dated 3/27/16 under the daily wound section and interventions revealed the nurse documented the dressing was changed and there was tunneling of the wound.

Review of the narrative section of the nurse note dated 3/27/16 revealed the following wound care documentation: "Dressing changed, removed dressing to Stage IV sacral decubitus ulcer. Tunneling equal to 2-3 inches in depth. Cleaned, packed with wet 4x4 gauzes. Covered with AD (ABD) pads. Secured with tape".

Further review of the physician orders revealed no specific order for wound care was obtained or written.

Review of the physician orders dated 3/28/16 revealed the following wound care order:

Cleanse sacral wound daily with NS (Normal Saline), apply cavilon to periwound area, apply moisture barrier over cavilon and then pack wound with Dakins soaked gauze and ABD (abdominal) pad and tape...

Review of the wound care nurse documentation dated 3/28/16 revealed the following assessment and wound care: " Cleanse wound with NS, apply cavilon and moisture barrier to periwound. Pack wound with NS soaked gauze and cover with ABD pad and tape"... " Area was well cleansed with wound cleanser, wound was packed with NS soaked gauze, moisture barrier was applied to periwound and covered with abd pad and tape".

Further review of the wound care nurse note dated 3/28/16 revealed the wound care nurse did not document any tunneling as did the nurse on 3/27/16. The wound care provided was not the wound care ordered per the physician order and there was inconsistent documentation by the nurses describing the wound and providing the wound care.

An interview was conducted on 3/30/16 at 1:40 PM with Employee Identifier (EI) # 1, Director of Clinical Services, who confirmed the above mentioned findings.

PICC:

Review of the nurses notes dated 3/26/16, 3/27/16 and 3/28/16 revealed the patient had a PICC line to the left and right Subclavian area. Further review revealed the nurses documented every 2 hours the site was cleaned with Chrorexidine (Chlorhexidine) Wipe daily.

An interview was conducted on 3/30/16 at 1:40 PM with EI # 1 who confirmed the PICC site is only cleaned every 7 days along with the dressing changed per the policy and not every 2 hours as documented.

3. MR # 5 was admitted to the facility on 2/17/16 with admitting diagnoses of Purulent Pericarditis, S/P (status post) Pericardial Window Placement.

Capillary Blood Glucose:

Review of the admission physician orders dated 2/17/16 revealed the following order:
Capillary Blood Glucose at 0700 (7:00 AM).

Review of the nurses notes dated 2/17/16 - 3/10/16 revealed Capillary Blood Glucose testing was not completed on the patient during the patient's entire hospital stay.

Chest Tube:

Review of the initial physician orders dated 2/17/16 revealed the following order:

Chest tubes to water seal.

Review of the nurses notes dated 2/17/16, 2/18/16, 2/19/16, 2/20/16, 2/21/16, 2/22/16, 2/24/16, 2/25/16 and 2/29/16 revealed no documentation under the respiratory section of the note for the type of chest tube or the condition of the chest tube dressing.

An interview was conducted on 3/30/16 at 1:40 PM with EI # 1 who confirmed the lack of documentation on the chest tube.

Wound:

Review of the physician orders dated 2/17/16 revealed the following order:

Clean wound daily.

Review of the nursing assessment dated 2/17/16 revealed the patient had an old chest tube site to right axilla and a chest tube to the mid abdomen. Further review revealed no documentation the old chest tube site or the chest tube was assessed or the dressing was changed to the chest tube site.

Review of the physician order dated 2/18/16 revealed the following order:

Cleanse chest tube site PRN (as needed) for soiling. Apply Xeroform gauze around base of tube; cover with 4x4 (4x4 gauze) to lower ABD (abdominal) tape lightly.

Review of the nurse note dated 2/18/16 revealed the daily wound assessment section of the note the nurse documented the sites were being assessed by the wound care nurse.

Review of all the nurses notes in the MR revealed no documentation by the wound care nurse of an assessment of either site.

Further review of the nurse note dated 2/18/16 revealed from 8:00 AM to 6:00 PM under the interventions the nurses initials are present and there is no documentation as to what was completed every 2 hours.

Review of the nurse note dated 2/19/16 under the daily wound assessment and the interventions revealed these 2 sections were left blank.

Review of the nurse noted dated 2/20/16 under the interventions for the daily wound assessment revealed at 8:00 AM the nurse placed initials and it is undetermined what intervention was provided at that time.

Review of the nurse note dated 2/21/16 under the daily wound assessment interventions revealed a check mark under 2000 (8:00 PM) for the midsternal chest tube and it is undetermined what interventions were completed.

Review of the nurse note dated 2/22/16 revealed the daily wound assessment and the interventions were blank for both shifts.

Review of the nurse noted dated 2/24/16 under daily wound assessment revealed the section is blank. Further review of the interventions revealed initials at 8:00 AM and it is undetermined what interventions were performed.

Review of the nurse note dated 2/25/16 revealed under daily wound assessment the nurse documented the patient is being seen by the wound care nurse. Review of all the nurse notes revealed no documentation by the wound care nurse.

Further review of the nurse note 2/25/16 revealed under the interventions the nurses' initials under 8:00, 10:00 AM and 12:00, 2:00, 4:00 and 6:00 PM and it is undetermined what interventions were performed.

An interview was conducted on 3/30/16 at 9:00 AM with EI # 1 who confirmed the documentation for the wound site for the chest tube was incomplete and inconsistent.

PICC:

Review of the nurses notes dated 2/18/16, 2/25/16, 3/2/16, 3/5/16, 3/6/16, 3/9/16 and 3/10/16 revealed the nurses documented site cleaned with Chlorhexidine wipe daily.

An interview was conducted on 3/30/16 at 9:00 AM with EI # 1 who confirmed the above mentioned findings.



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4. MR # 2 was admitted to the facility on 3/10/16 with admitting diagnoses of Enterocutaneous Fistula, Ogilivie Syndrome, Hypertension, and Protein Calorie Malnutrition.

Wound:

Review of the physician's ordered dated 3/10/16 revealed the following wound care orders, cleanse abd wound daily & prn with NS; cover open areas with Aquacel and NS dampened gauze, abd pad and tape. Notify wound care if any changes; example - excessive drainage or wound dehiscence.

Review of the initial wound assessment dated 3/10/16 completed by the wound nurse revealed the patient had an area which covered an area 15 cm (centimeters) long, 0.5 cm wide and 0.0 cm deep. There was scant serous drainage.

Review of the medical record on 3/30/16 revealed no documentation of a Nurse's 24 Hour Assessment and Progress Record for 3/11/16.

Review of the Nurse's 24 Hour Assessment and Progress Records for 3/13/16, 3/19/16, 3/24/16, and 3/28/16 revealed no/incomplete documentation of a wound assessment.

Review of the medical record on 3/30/16 revealed no documentation by the wound nurse until 3/22/16, which was 12 days after 3/10/16.

Review of the wound assessment completed by the wound nurse on 3/22/16 revealed the patient had an area 15 cm long, 0.5 cm wide and 0.0 cm deep. There was scant serous drainage. There was no documented evidence the wound had improved.

Further review of the wound assessment completed by the wound nurse on 3/22/16 revealed documentation the wound nurse cleansed the wound with soap and water and applied a clean dry dressing. There was no documentation of a physician's order for the above wound care.

Review of the Nurse's 24 Hour Assessment and Progress Records revealed no documentation the dressing was dry and intact on:

3/10/16 between 10:00 AM and 3/12/16 at 8:00 AM.
3/12/16 between 8:00 AM and 3/13/16 at 8:00 AM.
3/13/16 between 8:00 AM and 3/14/16 at 3:00 PM.
3/15/16 between 8:00 AM and 3/16/16 at 8:00 AM.
3/16/16 between 8:00 AM and 3/17/16 at 8:00 AM.
3/17/16 between 10:00 AM and 3/20/16 at 8:00 PM.
3/23/16 between 8:00 AM and 3/24/16 at 8:00 AM.
3/24/16 between 8:00 AM and 3/25/16 at 8:00 AM.
3/25/16 between 8:00 AM and 3/26/16 at 8:00 AM.
3/26/16 between 8:00 AM and 3/28/16 at 8:00 AM.

Review of the medical record on 3/30/16 revealed no documentation wound care was provided on 3/25/16 and 3/28/16.

An interview was conducted on 3/31/16 at 7:35 AM with EI # 2, Director of Quality Management who stated the wound nurse was to assess the wounds 1 time a week and the nursing staff were to assess the patient at least every shift. EI # 2 verified the above findings.

PICC:

Review of the Admission Skin Assessment dated 3/10/16 revealed the patient had a PICC line in the right antecubital fossa.

Review of the Nurse's 24 Hour Assessment & Progress Records revealed documentation the CVL (Central Venous Line) site was cleaned with Chlorhexidine wipe at:

3/10/16 = 10:00 AM, 12:00, 2:00 and 4:00 PM.
3/11/16 = no documentation of a Nurse's 24 Hour Assessment & Progress Record.
3/12/16 = every 2 hours between 8:00 AM and 10:00 PM.
3/15/16 = dressing changed at 9:53 AM.
3/16/16 = 8:00 AM, 2:00, 4:00 and 6:00 PM.
3/18/16 = every 2 hours between 7:00 AM and 7:00 PM.
3/22/16 = There was no documentation the CVL dressing had been changed, which was 7 days after 3/15/16.
3/24/16 = every 2 hours between 8:00 AM to 3/25/16 at 6:00 AM.
3/25/16 = revealed the dressing was changes on 3/22/16.
3/26/16 = every 2 hours between 8:00 AM and 8:00 PM.
3/27/16 = every 2 hours between 8:00 AM and 8:00 PM.

An interview was conducted on 3/31/16 at 7:35 AM with EI # 1, who verified the above.



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5. MR # 3 was admitted to Hospital on 3/11/16 with a diagnosis including Clostridium Difficile Colitis (C-Diff), UTI, Heart Disease, Diabetes Mellitus (DM), Cerebrovascular Accident (CVA/Stroke), and Protein Calorie Malnutrition (PCM).

Review of nursing note dated 3/11/16 revealed wound care was documented to sacral area. Review of Admission Skin Assessment form dated 3/11/16 revealed no documentation on the body diagrams indicating the location of skin integrity issues.

Review of the nurse note dated 3/12/16, and 3/13/16 revealed an incomplete skin assessment. The body diagram was not marked to show where skin integrity issues were located.

Review of Wound-Tracc order form dated 3/14/16 revealed that patient was admitted with a wound to the patient's perineum / sacral area. The wound was 13.0 cm in length, 8.0 cm in width, and 0.1 cm in depth. The site was red with denuded tissue and some scaliness noted.

Review of the physician order dated 3/14/16 revealed an order for wound care: "cleanse sacral and perineal area daily and prn soiling with soap and water. Apply Elta ointment and moisture barrier and leave open to air - (May cover with Mepilex), elta ointment to heels, ankles, elbows, ears daily for prevention. Left to Right turns every two hours and float heels".

Review of the nurse note dated 3/15/16 revealed no documentation found on sacral wound care and wound assessment.

Review of the nurse notes dated 3/16/16, 3/21/16, and 3/26/16 under the daily wound assessment and interventions sections revealed these sections were blank.

Review of the nurse note dated 3/19/16 revealed no documentation under daily wound intervention section for wound assessment.

Review of the nurse notes dated 3/19/16, and 3/20/16 no documentation the patient (pt) was turned every 2 hours as ordered. Further review of the activity section on the nurse notes dated 3/19/16 and 3/20/16 revealed the pt was turned at 5:00 PM and not again until 8:00 PM, which was 3 hours.


An interview was conducted on 3/30/16 at 3:10 PM with EI # 3 who confirmed the above mentioned findings.

Based on review of medical records (MR), facility policy and interviews it was determined the facility failed to ensure each patient's Plan of Care (POC) was complete and up to date to meet the patients needs. This affected 4 of 5 MR's reviewed and did affect MR # 6, MR # 1, MR # 5, MR # 3, and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Nursing Plan of Care (POC)
Policy Number: 20-03054
Revision Date: 10/1/14

The Nursing Process us utilized in assessing, planning, implementing and evaluating patient care. The process will be continuous and documentation will be appropriate to each step. Needs are assessed within twenty-four hours of admission, and throughout the patient's stay...The patient's Plan of Care will serve as a guide for Registered Nurses (RN) and other staff members in the delivery of patient care...

Patient care is evaluated or reassessed by the RN to determine progress or lack of progress toward goals and need for revision of Plan of Care...


1. MR # 6 was admitted to the facility on 2/23/16 with diagnoses including Congestive Heart Failure, Coronary Artery Disease, Status Post Bypass Times 4, and Mitral Valve Regurgitation with Mitral Valve Repair, and Continued Dobutamine (used to treat acute but potentially reversible heart failure) Therapy.

Review of the IDT and POC Conference dated 2/23/16 revealed the following:

Case Management: No documentation of discharge planning, anticipated discharge date, or a goal.

Blood Glucose: Documented interventions included Fasting Blood Sugar, Sliding Scale Insulin and to Monitor laboratory values. There was no documentation of a goal.

Cardiovascular: No documentation of interventions or a goal even though this patient was admitted for Dobutamine Therapy.

Neurological: Intervention included Assess LOC (Level of Consciousness). There was no documentation of a goal.

Intravenous Therapy: Included Dobutamine Drip. There was no documentation of a goal.

Knowledge Deficit: Patient was admitted with multiple diagnoses and teaching of each was needed along with family education.

CLABSI (Central Line Acquired Blood Stream Infection)- Protocol: This was left blank even though the patient was admitted with a central line to administer Dobutamine.

The Team Action Plan revealed this section only included Dobutamine drops. There was no documentation the plan was discussed with the family.

Review of the IDT and POC Conference dated 3/3/16 revealed the following:

Case Management: No documentation of discharge planning or anticipated discharge date.

Knowledge Deficit: Patient was admitted with multiple diagnoses and teaching of each was needed along with family education.

Skin Impairment: No documentation of interventions or goals. The patient had an unstageable wound to the sacral area that measured 14 cm (centimeters) long and 13 cm wide. The patient also had a low air loss mattress.

CLABSI - Protocol: This was left blank even though the patient was admitted with a central line to administer Dobutamine. The central line the patient was admitted with malfunctioned and the patient had it replaced 2/17/16.

Review of the IDT and POC Conference dated 3/10/16 revealed the following:

Case Management: No documentation of discharge planning or anticipated discharge date. Goal included wean Dobutamine drops. This was the last day of Dobutamine.

Code Status, Blood Glucose, Cardiovascular, and Intravenous Therapy had a x thru all interventions and goals. There was no documentation these areas were active.

An interview was conducted on 3/31/16 at 8:20 AM with EI # 1, who verified the above.

2. MR # 1 was admitted to the facility on 3/25/16 with an admitting diagnosis of Sepsis, Respiratory Failure, Infective Stage 4 Sacral Ulcer, VRE ( Vancomycin Resistant Enterococcus), E.coli (Escherichia coli) and UTI (Urinary Tract Infection).

Review of the Interdisciplinary Team (IDT) Conference POC dated 3/25/16 revealed the following interventions were not initiated on admission:

Cardiovascular: Patient was connected to the bedside cardiac monitor

Knowledge Deficit: Patient was admitted with multiple diagnoses and teaching of each was needed along with family education.

Elimination: Patient had a foley catheter to be monitored.

Skin Integrity: Low - Moderate: Patient's Braden Scale score was 17 which indicated a low to moderate risk and skin integrity should have been initiated.

CAUTI (Catheter-Associated Urinary Tract Infections) The patient had a foley catheter which needed monitoring.

The Team Action Plan revealed this section was not initiated and discussed by the team and there is no documentation the physician signed the POC.

Review of the IDT conference revealed the following interventions had documentation but lacked a date and if the POC was the initial or continued POC:

Nutrition: No documentation of date or whether it was the initial POC or a continued POC.

General Nutrition: No documentation of date or whether it was the initial POC or a continued POC.

An interview was conducted on 3/30/16 at 1:40 PM with Employee Identifier (EI) # 1, Director of Clinical Services, who confirmed the above mentioned findings.

3. MR # 5 was admitted to the facility on 2/17/16 with admitting diagnoses of Purulent Pericarditis, S/P (status post) Pericardial Window Placement.

Review of the MR revealed the following MD (Medical Doctor) orders dated 2/17/16 on admission:

(Intravenous) IV access: Other: PICC (Peripherally Inserted Central Catheter)
Capillary Blood Glucose at 0700 (7:00 AM)
Respiratory Management: 3 l/min (liters per/minute) Nasal Cannula

Review of the IDT POC dated 2/17/16 revealed the following interventions were not initiated on admission:

Blood Glucose: Patient was to receive Blood Glucose monitoring every morning at 7:00 AM

Intravenous Therapy (IV): Patient has a PICC line and receiving IV antibiotics.

Supplemental Oxygen (O2): The patient was using O2 at 3 l/min.

An interview was conducted on 3/30/16 at 9:00 AM with EI # 1 who confirmed the above mentioned findings.



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4. MR # 3 was admitted to Hospital on 3/11/2016 with a diagnosis including Clostridium Difficile Colitis (C-Diff), UTI, Heart Disease, Diabetes Mellitus (DM), Cerebrovascular Accident (CVA/Stroke), and Protein Calorie Malnutrition (PCM).

Review of Admission Orders dated 3/11/2016 revealed # 8. Isolation: Contact Enteric (C-Diff) and # 10. Wound Care: Wound Care Nurse to evaluate and treat.

Review of Medication Reconciliation and Physician orders dated 3/11/16 revealed as needed (PRN) pain medication.

Review of the Nursing Admission Assessment / Screens dated 3/11/16 revealed the patient (pt) was not oriented for isolation. Review of initial nursing note dated 3/11/16 revealed pt was hard of hearing.

Review of the IDT Conference POC dated 3/11/16 revealed no interventions listed under the following sections: Blood Glucose, communication, skin integrity and comfort/pain section.

Review of Wound-Tracc order form dated 3/14/2016 revealed this patient was admitted with a wound to his perineum / sacral area. The wound was 13.0 centimeters (cm) in length, 8.0 cm in width, and 0.1 cm in depth. The site was red with deduded tissue and some scaliness noted.

An interview was conducted on 3/30/16 at 3:10 PM with EI # 2, Director of Quality Management, who confirmed the above mentioned findings.



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Based on the review of the Medical Records (MR), facility policy and interview, it was determined the facility failed to ensure the licensed nurse assessed the effectiveness of pain relief interventions in 1 of 5 records reviewed. This included MR # 6 and had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: Pain Assessment and Management Guidelines
Policy #: 20--3046
Effective Date: 10/01/14

Guidelines:

Patient have the right to treatment of their pain within the confines of current healthcare advances and to maintain the patient's comfort...

Routine Assessment & Treatment/Re-Assessment:

2. The licensed nurse should also assess for and document the effectiveness of a pain relief intervention at approximately one hour (or sooner) after a pain relief intervention is employed.

1. MR # 6 was admitted to the facility on 2/23/16 with Diagnoses including Congestive Heart Failure, Coronary Artery Disease, Status Post Bypass Times 4, and Mitral Valve Regurgitation with Mitral Valve Repair.

Review of the physician's orders dated 2/23/16 revealed an order for Tylox 5/325 1 by mouth every 4 hours for moderate pain.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 2/29/16 at 2:45 PM revealed the patient complained of pain at a level of 7 (scale of 0 being no pain and 10 being the worst). The nurse administered Tylox. There was no documentation the nurse reassessed for the effectiveness of the Tylox.

Review of the Medication Administration Record dated 3/8/16 revealed the nurse administered Tylox at 7:55 PM. There was no documentation of the patient's pain level or the nurse had reassessed for the effectiveness of the Tylox.

Review of the Nurse's 24 Hour Assessment and Progress Record dated 3/9/16 at 10:00 AM revealed the nurse administered Tylox for a pain level of 7. There was no documentation the nurse reassessed for the effectiveness of the Tylox. At 2:00 PM the patient required a second dose of Tylox for a pain level of 5 and there was no documentation the nurse reassessed for the effectiveness. The patient required a third Tylox at 10:40 PM with an illegible level of pain.

An interview was conducted on 3/31/16 at 8:20 AM with Employee Identifier # 1, Director of Clinical Services who verified the above documentation.

Based on review of medical records (MR), facility policies and interviews with the staff it was determined the facility failed to ensure:

a) Proper documentation was in the MR to ensure the blood product was given within 30 minutes from obtaining from the blood bank.

b) TPN (Total Parenteral Nutrition) solution was changed every 24 hours.

c) Dobutamine drip was accurately monitored and documented.

This affected 4 of 5 MR reviewed and did affect MR # 6, MR # 1, MR # 2, MR # 3 and had the potential to negatively affect all patients served by the agency.

Findings include:

Policy: Blood/Blood Products: Transfusion therapy
Policy Number: 20-03007
Revision Date: 01/26/2009

Guidelines:

Blood Transfusions will be administered by RN's (Registered Nurse) upon order of physician.

E. Initiation and timing of transfusion:
2. If transfusion is not begun within 30 minutes after receipt of blood/blood products from the Blood Bank, blood must be returned unused.

************

Policy: TPN-Total Parenteral Nutrition, Administration of
Policy Number: 20-03069
Effective Date: 10/01/14

Guideline: Total Parental Nutrition (TPN) is the intravenous infusion of essential nutrients, ordered by the physician when it is impossible or inadvisable to use the normal digestive route...

3. Nursing Priorities in TPN Therapy Maintenance

c. Ensures TPN solution is changed every twenty-four (24) hours.


1. MR # 6 was admitted to the facility on 2/23/16 with Diagnoses including Congestive Heart Failure, Coronary Artery Disease, Status Post Bypass Times 4, Mitral Valve Regurgitation with Mitral Valve Repair and Continued Dobutamine Therapy.

Review of the physician's order dated 2/23/16 at 12:30 PM revealed orders for Dobutamine at a rate of 5 cc (cubic centimeters) x 3 weeks. There was no clear documentation in this order of the rate per minute or hour.

Review of the Medication Reconciliation and Physician's Order dated 2/23/16 at 1:50 PM revealed and order as follows:

Dobutamine 500/D5W (5% dextrose in water) 250 IV (intravenous) 5 mcg (micrograms)/kg (kilogram)/min (minute) for 7 days (2/18/16 started).

Dobutamine 500/D5W 250 IV 3 mcg/kg/min x 7 days (2/25/16)

Dobutamine 500/D5W 250 IV 2 mcg/kg/min x 7 days (3/3/16)

Review of the Nurse's 24 Hour Assessment and Progress Note dated 2/23/16 at 2:00 PM revealed the patient had Dobutamine infusing at 5 mcg/kg/min. The documentation at 12:00 AM was illegible if the Dobutamine was infusing at 5 mcg or mg/kg/ min or hour.

Review of the Nurse's 24 Hour Assessment and Progress Notes dated 2/24/16 at 8:00 AM revealed the Dobutamine was infusing at 5 mg/kg/min. There was no documentation on the 7 PM to 7 AM shift of the Dobutamine rate of infusion.

Review of the Nurse's 24 Hour Assessment and Progress Note dated 2/25/16 revealed no documentation of the Dobutamine rate of infusion.

Review of the Nurse's 24 Hour Assessment and Progress Note dated 2/26/16 revealed no documentation of the Dobutamine rate of infusion until 2/27/16 at 2:00 AM; which included, "Dobutamine continues as ordered." At 4:00 AM the documentation included 9.8 ml. There was no documentation on the mcg/kg/min. The order rate of the Dobutamine was ordered to be decrease to 3 mcg/kg/min. on 2/25/16.

Review of the Nurse's 24 Hour Assessment and Progress Note dated 2/27/16 revealed no documentation of the Dobutamine rate of infusion.

Review of the Nurse's 24 Hour Assessment and Progress Note dated 2/28/16 revealed no documentation of the Dobutamine rate of infusion. At 10:00 PM the nurse documented, "Dobutamine infusion continues."

Review of the Nurse's 24 Hour Assessment and Progress Note dated 2/29/16 at 11:15 AM and 10:05 PM, revealed the first clear documentation of the Dobutamine rate of infusion since 2/24/16 at 8:00 AM, which was 3 mcg/kg/min = 9.8 ml (milliliters)/hour.

Review of the Nurse's 24 Hour Assessment and Progress Note dated 3/1/16 at 8:50 AM revealed the nurse documented the Dobutamine was infusing at 3 mcg 9.8 cc. There was no documentation of the rate. At 10:00 PM, the nurse documented the Dobutamine was infusing at 9.8 cc/hour.

Review of the MAR between 2/23/16 and 3/4/16 revealed no documentation the staff administered the Dobutamine until 3/4/16 at 7:30 AM, which was to infuse at 2 mcg/kg/min.

Review of the Nurse's 24 Hour Assessment and Progress Note dated 3/8/16 revealed no documentation of the Dobutamine rate on the 7:00 AM to 7:00 PM shift. The nurse documented at 10:00 PM, the Dobutamine rate was at 2 (illegible amount)/(illegible weight)/(illegible time).

Review of the Nurse's 24 Hour Assessment and Progress Note dated 3/9/16 revealed no documentation of the rate of the Dobutamine infusion.

Review of the physician's order dated 3/12/16 at 9:45 AM revealed an order to discontinue the Dobutamine drip. The Dobutamine drip was ordered to be completed on 3/10/16.

There was no documentation in the medical record on 3/31/16 when the Dobutamine infusion was completed or an accurate record of the infusion.

An interview was conducted with EI # 1 on 3/31/16 at 8:20 AM. EI # 1 confirmed the above findings.

2. MR # 1 was admitted to the facility on 3/25/16 with admitting diagnoses of Sepsis, Respiratory Failure, Infective Stage 4 Sacral Ulcer, VRE (Vancomycin Resistant Enterococcus), E.coli (Escherichia coli) and UTI (Urinary Tract Infection).

Review of the physician order dated 3/28/16 revealed the following order: T & C (type and cross match) 2 units PRBC (packed red blood cells)
Transfuse 2 units PRBC...

Review of the Blood Administration Documentation Flowsheet dated 3/28/16 and 3/29/16 revealed no documentation of the time the blood product was picked up by the nurse at the blood bank.

Further review of the Blood Administration Documentation Flowsheet revealed no documentation of whether the blood product was started within the 30 minute time frame.

Review of the Nurse's 24 hour Assessment and Progress Record dated 2/28/16 revealed no documentation of the time the blood product was obtained from the blood bank.

An interview was conducted on 3/30/16 at 1:40 PM with Employee Identifier (EI) # 1, Director of Clinical Services, who confirmed the above mentioned and stated there is no documentation in the chart to confirmed the time the blood was picked up at the blood bank.



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3. MR # 2 was admitted to the facility on 3/10/16 with admitting diagnoses of Enterocutaneous Fistula, Ogilivie Syndrome, Hypertension, and Protein Calorie Malnutrition.

Review of the physician order date 3/10/16 revealed orders for TPN to run at 80 ml (milliliters)/hour.

Review of the Medication Administration Records (MAR) between 3/10/16 and 3/28/16 revealed no documentation the TPN was changed on 3/15/6, 3/16/16, 3/17/16, 3/22/16, 3/27/16 and 3/28/16.

Review of the physician order dated 3/25/16 revealed the following order:
type, cross and transfuse 1 unit PRBC in AM.

Review of the Blood Administration Documentation Flowsheet dated 3/26/16 revealed no documentation of the time the blood product was picked up by the nurse at the blood bank.

Further review of the Blood Administration Documentation Flowsheet revealed no documentation of whether the blood product was started within the 30 minute time frame.

Review of the Nurse's 24 hour Assessment and Progress Record dated 3/26/16 revealed no documentation of the time the blood product was obtained from the blood bank.

An interview was conducted on 3/30/16 at 1:40 PM with EI # 2, Director of Quality Management, who confirmed the above findings and stated there is no documentation in the chart to confirmed the time the blood was picked up at the blood bank or when TPN was changed on the above dates.



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4. MR # 3 was admitted to Hospital on 3/11/2016 with a diagnosis including Clostridium Difficile Colitis (C-Diff), UTI (Urinary Tract Infection), Heart Disease, Diabetes Mellitus (DM), Cerebrovascular Accident (CVA), and Protein Calorie Malnutrition.
Review of the physician order date 3/12/16 revealed orders for TPN to run at 50 ml (milliliters)/hour.

Review of the Medication Administration Records (MAR) between 3/13/16 to 3/14/16, and 3/14/16 to 3/15/16 revealed two TPN labels on the MAR without distinctive dates, times started and stopped.

Review of MAR dated 3/16/16 to 3/17/16 revealed a TPN label dated 3/16/16, and time 0001.

Review of MAR dated 3/17/16 to 3/18/16 revealed a TPN label dated
3/16/16, and time 2000.

Review of MAR dated 3/20/16 to 3/21/16, and 3/21/16 to 3/22/16 revealed two TPN labels without documentation of what nurse initiated the TPN, what time it was initiated and there was no way to distinguish what date they were administered.

An interview was conducted on 3/30/16 at 3:10 PM with EI # 3 who confirmed the above mentioned findings.

Based on review of the medical records (MR), facility policy and interviews with the staff it was determined the facility failed to ensure all physician orders were written and in the MR. This affected 2 of 5 MR's reviewed and did affect MR # 5 and MR # 1 and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Telephone and Verbal Orders-Pharmacy
Policy Number: 20-06074
Revision Date: 3/1/08

Guideline:
Telephone and verbal orders for administration of medications may be received and recorded by pharmacists and other licensed personnel lawfully authorized to administer drugs...

Telephone orders for medication may be prescribed in the following instances:
1. The prescribing practitioner has determined that the patient is in need of medication within a specific time period and he/she is unable to physically write the order in the patient's medical record due to his/her physical location...

Procedure:
...All verbal/telephone orders of medication shall be immediately transcribed in writing into the medical chart of the patient...

1. MR # 5 was admitted to the facility on 5/17/16 with admitting diagnoses of Purulent Pericarditis, S/P (status post) Pericardial Window Placement.

Review of the initial physician orders dated 2/17/16 revealed the following orders, "... Respiratory Management: 3 l/min (liters per minute) Nasal Cannula..."

Review of the Nurses notes dated 2/18/16, 2/19/16, 2/23/16, 2/24/16, 2/25/16, 2/26/16, 2/27/16, 2/28/16, 3/4/16, 3/5/16 and 3/7/16 revealed the nurse documented the patient was using Oxygen (O2) at 2 l/min.

Review of all the physician orders revealed no order was written for O2 at 2 l/min.

Review of the nurse note dated 2/21/16 revealed the nurse documented the patient was using O2 at 3 l/min PRN (as needed).

Review of all the physician orders revealed no documentation an order was written for the O2 at 3 l/min PRN.

An interview was conducted on 3/30/16 at 1:40 PM with Employee Identifier (EI) # 1, Director of Clinical Services, who confirmed the above mentioned findings.

2. MR # 1 was admitted to the facility on 3/25/16 with an admitting diagnosis of Sepsis, Respiratory Failure, Infective Stage 4 Sacral Ulcer, VRE ( Vancomycin Resistant Enterococcus), E.coli (Escherichia coli) and UTI (Urinary Tract Infection).

Review of the physician order dated 3/26/16 revealed the following orders:

Wound care.

There was no documentation the above physician order was clarified for specific wound care orders.

Review of the nurse note dated 3/27/16 under the daily wound section and interventions revealed the nurse documented the dressing was changed.

Review of the narrative section of the nurse note dated 3/27/16 revealed the following wound care documentation: "Dressing changed, removed dressing to Stage IV sacral decubitus ulcer. Tunneling equal to 2-3 inches in depth. Cleaned, packed with wet 4x4 gauzes. Covered with AD (ABD) pads. Secured with tape".

Further review of the physician orders revealed no specific order for wound care was obtained or written and no order written for the wound care that was provided.

Review of the physician orders dated 3/28/16 revealed the following wound care order:

Cleanse sacral wound daily with NS (Normal Saline), apply cavilon to periwound area, apply moisture barrier over cavilon and then pack wound with Dakins soaked gauze and ABD (abdominal) pad and tape...

Review of the wound care nurse documentation dated 3/28/16 revealed the following assessment and wound care: " Cleanse wound with NS, apply cavilon and moisture barrier to periwound. Pack wound with NS soaked gauze and cover with ABD pad and tape"... " Area was well cleansed with wound cleanser, wound was packed with NS soaked gauze, moisture barrier was applied to periwound and covered with abd pad and tape".

Further review of the wound care nurse note dated 3/28/16 revealed the wound care nurse did not provide the wound care which was ordered. There was no documentation of a physician's order for the wound care as it was provided above.

An interview conducted on 3/30/16 at 1:40 PM with EI # 1, who confirmed the above mentioned findings and agreed no orders were written for the O2 at 2 l/min, the physician ordered wound care was not performed and there was no clarification for specific wound care orders.

Based on observations, review of the facility's policies and interview, it was determined the facility failed to ensure the staff performed hand hygiene according to their own policy.

This had the potential to negatively affect all patients served by this facility and the staff who cared for them.

Findings include:

Facility Policy: Isolation Precautions
Policy #: 20-05013
Effective Date: 10/01/14

Contact Isolation:

Purpose:

Designed to prevent transmission of know or suspected serious illness (or colonization) easily transmitted by direct patient contact or by contact with items in the patient's environment.

Equipment:

4. Gloves are indicated for touching infective material.

5. Hands will be washed before taking care of another patient.

Facility Policy: Hand Hygiene
Policy #: 20-05009
Effective Date: 10/01/14

Policy:

Handwashing is considered to be the single most important procedure in the prevention of the spread of infections. All personnel will wash their hands according to this procedure:

Procedure:

2. Hands must be cared for by handwashing with soap and water or by hand antisepsis with alcohol-based hand rub (if hands are not visibly soiled);

a. Before and after patient contact.

c. After removing gloves.

During observations of care on 3/29/16 between 8:15 AM and 8:45 AM, the surveyor observed Employee Identifier (EI) # 6, Patient Care Technician donned a gown and a pair of gloves, entered a contact isolation patient's room, removed the gown and gloves and exited the room 3 times in a row without hand hygiene.

An interview was conducted with EI # 1, Director of Clinical Services on 3/31/16 at 9:00 AM. EI # 1 stated the staff are to perform hand hygiene after removing a pair of gloves and exiting a contact isolation room.

Based on review of employee files, facility policy and interviews, it was determined the facility failed to ensure all employees received testing and / or review of TB (Tuberculosis) on an annual basis according to the facility policy. This affected 1 of 2 employee files reviewed.

Findings include:

Policy: Employment Medical Examination (Initial and Annual Requirements).
Policy Number: HD-HR 205.10
Revision Date: 8/1/15

Documentation of TB skin test results (within the previous twelve months) must be presented at the time the post offer employment examination is administered...

Subsequent annual review of TB for all employees, will be accomplished through the completion of the TB status form...

Review of Employee Identifier (EI) # 3, Wound Care Nurse's health file revealed documentation of a TB skin test performed on 3/17/15. Further review revealed no documentation of an annual TB skin test for the year 2016 and no documentation of a TB status form for the year of 2016.

An interview was conducted on 3/30/16 at 1:40 PM with EI # 1, Director of Clinical Services, who confirmed the above mentioned findings.

Based on the review of medical records (MR) and interviews, it was determined the facility failed to ensure there were physician's orders for therapy and therapy followed their own plan of care in 3 of 5 records reviewed. This affected MR # 2, 1, 3 and had the potential to affect all patients served by this facility.

Findings include:

1. MR # 2 was admitted to the facility on 3/10/16 with admitting diagnoses of Enterocutaneous Fistula, Ogilivie Syndrome, Hypertension, and Protein Calorie Malnutrition.

Review of the physician's orders dated 3/10/16 revealed the area to include Physical Therapy (PT) and Occupational Therapy (OT) evaluations were left blank.

Review of the Physical Therapist Evaluation revealed a plan of 3 times a week. Review of the PT Progress Notes revealed only 1 therapy treatment was conducted during the weeks of 3/21/16 and 3/28/16.

Review of the OT Progress Notes revealed no documentation of an OT treatment for the week of 3/28/16.

An interview was conducted on 3/31/16 at 8:00 AM with Employee Identifier (EI) # 2, Director of Quality Management. Review of the medical record with EI # 2 on 3/31/16 at 8:00 AM, revealed the only PT Progress Note for the week of 3/28/16, was completed on 3/28/16 and no OT Progress Notes for the week of 3/28/16. EI # 2 also verified there was no documentation of a physician's order for therapy.

2. MR # 1 was admitted to the facility on 3/25/16 with an admitting diagnosis of Sepsis, Respiratory Failure, Infective Stage 4 Sacral Ulcer, VRE (Vancomycin Resistant Enterococcus), E.coli (Escherichia coli) and UTI (Urinary Tract Infection).

Review of the physician orders dated 3/26/16 revealed and order for OT/PT.

Review of the OT/PT notes revealed the initial assessments were not completed until 2 days later on 3/28/16. The surveyor was informed by EI # 1, Director of Clinical Services the PT and OT are not scheduled to work on the weekends and that is why the initial evaluations were not completed until Monday 3/28/16.

An interview was conducted on 3/30/16 at 1:40 PM with EI # 1, Director of Clinical Services, who confirmed the above mentioned findings.



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3. MR # 3 was admitted to Hospital on 3/11/2016 with a diagnosis including Clostridium Difficile Colitis (C-Diff), UTI, Heart Disease, Cerebrovascular Accident (CVA/Stroke), and Protein Calorie Malnutrition (PCM).

Review of the Nursing Admission Assessment/Screens dated 3/11/2016 revealed patient (pt) fall risk was high and to consult PT/OT. There was no documentation of the initial orders for PT / OT.

Review of Physical Therapy initial evaluation dated 3/14/2016 revealed pt was evaluated and would be seen three times per week and progress as patient tolerates.

Review of Occupational Therapy notes dated 3/15/2016 revealed patient was evaluated and would be seen three times per week the first week.

An interview was conducted on 3/30/16 at 3:10 PM with EI # 2 verified the above findings.

An interview was conducted on 3/31/16 at 8:00 AM with EI # 2. The surveyor asked EI # 2 what the general rule for the hospital on getting a patient up to the restroom and/or ambulating.

EI # 2 stated, "If the patients calls the nurse's station and wants to ambulate to the bathroom and if the staff is able to we will go and help them. For ambulating, if PT documents the patient is good and steady and the patient wants to ambulate on the weekend, the staff will help them but if the PT is unsure about the patient's steadiness, then the staff will only transfer from the bed to a chair."