HospitalInspections.org

Based on medical record (MR) review, Alabama Board of Nursing (ABN) Administrative Code Standards of Nursing Practice, facility policy, and interview, it was determined facility nursing staff failed to:

1. Weigh patient daily as ordered by the physician.

2. Perform and document constant floating of heels as ordered by the physician.

3. Apply barrier cream to the buttocks BID (twice daily) and PRN (as needed) as ordered by the physician.

4. Provide/offer hygiene/bathing daily.

5. Notify the physician of change in physical assessment.

6. Notify the physician of withholding an ordered medication.

7. Picc (Peripherally Inserted Central Catheter) dressing was completed per facility policy.

This deficient practice affected 7 of 10 records reviewed, including Patient Identifier (PI) # 5, PI # 1, PI # 9, PI # 8, PI # 2, PI # 4, and PI # 6, and had the potential to negatively affect all patients served by the facility.

Findings include:

Alabama Board of Nursing Administrative Code
Chapter 610-X-6
Standards of Nursing Practice

610-X-6-.04 Practice Of Professional Nursing (Registered Nurse Practice)

(1) The practice of professional nursing includes, but is not limited to:

...(g) Executing medical regimens according to approved medical protocols and standing orders, including administering medications and treatments prescribed by a legally authorized
prescriber.

610-X-6-.09 Assessment Standards.

(1) Patient assessment shall be provided in accordance with the definitions of professional nursing and practical nursing, as defined in the Alabama Nurse Practice Act, Section 34-21-1.

(2) The registered nurse shall conduct and document comprehensive and focused nursing assessments of the health status of patients by:

(a) Collecting objective and subjective data from observations, physical examinations, interviews, and written records in an accurate and timely manner, as appropriate to the
patient's health care needs.

(b) Analysis and reporting of data collected.

Facility Policy: CLABSI Prevention
Policy Number: 605
Review Date: 2/16/22

Policy:

Central venous catheters are any catheters, regardless of type or insertion site, whos tip ends in the central venous circulation, including subclavian, intrajugular, femoral, tunneled catheters, implanted ports and peripherally inserted intravenous catheters (PICC).

Prevention strategies: Maintenance:

1. Evaluate the catheter insertion site daily by palpation through the dressing to discern tenderness and by inspection if transparent dressing is in use...

2. Dressing changes should be conducted at least weekly or when visibly soiled...

1. PI # 5 was admitted to the facility on 2/21/22 with diagnoses including Covid Pneumonia, Essential Primary Hypertension, and Coronary Artery Disease. PI # 5 was discharged to an acute care facility on 3/6/22 due to a SIRS (systemic inflammatory reponse syndrome) alert.

Review of a print out provided by the faciity of all patient orders revealed physician orders for the following:

a. 2/22/22 2:39 AM - Barrier cream application, apply barrier cream BID and PRN as needed to buttocks. Ears, buttocks, and heels red.

b. 2/22/22 12:40 PM - Constant order, float heels when in bed.

c. 2/24/22 8:00 AM - Daily weight.

Review of the nursing assessment flowsheet provided by the faciity under the heading, "Intact Skin Variance Group," revealed barrier cream was not applied on 2/22/22, 2/23/22, 2/24/22, or 3/3/22, and only applied once on 2/25/22, 2/27/22, 2/28/22, 3/2/22, and 3/4/22.

Review of the nursing assessment flowsheet under the heading, "Activity ADLs (activities of daily living) Positioning/Pressure," revealed documentation of heels being floated on 2/22/22. There was no further documentation of heels being floated 2/23/22 through 3/6/22.

Review of the Vital Signs flowsheet provided by the facility revealed no weights were obtained and documented on 2/25/22, 2/27/22, 2/28/22, 3/1/22, 3/2/22, or 3/3/22.

Further review of the nursing assessment flowsheet under heading, "Bathing ADLs," revealed no documentation the patient was bathed or provided hygiene on 2/23/22, 2/24/22, 2/27/22, 2/28/22, 3/2/22, 3/3/22, or 3/5/22.

In an interview conducted on 3/10/22 at 2:20 PM with Employee Identifier (EI) # 1, Chief Nursing Officer (CNO), EI # 1 confirmed there was no documentation the barrier cream was applied BID as ordered, no documentation of heels being floated as ordered, and weights were not obtained daily as ordered. EI # 1 also confirmed bathing/hygiene was not documented as being provided on the dates identified, and when asked if there was a policy on bathing, EI # 1 stated there was no bathing policy, but the standard was to offer a bath daily.

2. PI # 1 was admitted to the facility on 2/16/22 with diagnoses including Encounter For Surgical AfterCare Following Surgery on the Circulatory System, and Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. PI # 1 was discharged to an acute care facility on 2/26/22 due to shortness of breath and an oxygen saturation of 85%.

Review of the physician order dated 2/16/22 at 1:21 PM revealed an order for the diuretic furosemide (lasix) 40 mg (milligrams), 1 tab (tablet) oral daily. Start Date 2/17/22 8:00 AM CST (central standard time), for 7 day(s). Stop date 2/24/22 7:59 AM CST.

Further review of physician orders dated 2/16/22 at 1:35 PM revealed an order for lasix 40 mg, 1 tab oral daily PRN as needed for weight > (greater than) 148 lbs (pounds). Start date 2/24/22 1:00 AM CST.

Review of the Vital View Flowsheet, date range 2/16/22 to 2/26/22, under the heading "Measurements," revealed a documented weight of 158 lbs on 2/24/22 at 4:43 PM CST.

Review of the Medication Administration Record (MAR) revealed no lasix was administered on 2/24/22 for weight > 148 pounds as ordered.

Review of the IView nursing assessment dated 2/24/22 at 8:56 AM revealed the nurse documented PI # 1 had 2 plus (+) pitting edema to left lower leg, 1 + pitting edema to right lower leg, and crackles were ausculated in bilateral lower lobes of the lungs.

There was no documentation the nurse notified the physician of his/her assessment.

In an interview conducted on 3/10/22 at 2:37 PM, EI # 1 stated the nurse held the lasix ordered PRN for weight of 158 pounds on 2/24/22 due to PI # 1 had a low blood pressure of 98/67. The surveyor asked if the nurse notified the physician the lasix was held, and EI # 1 stated the physician was not notified lasix was held and should have been. EI # 1 also confirmed the nurse did not document notifying the physician of his/her 2/24/22 8:56 AM assessment findings and should have.


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3. PI # 9 was admitted to the facility on 2/7/22 with admitting diagnoses of Covid 19, Acute Kidney Injury (AKI) and Muscle Weakness Generalized and discharged on 3/8/22.

Wound Care:

Review of the physician orders dated 2/10/22 revealed the following orders for wound care:

Thigh/Perineum: Clean with soap and water Bid, clean perineum and inner thighs with soap and water, pat dry, apply antifungal barrier cream bid and PRN.

Left Buttock: Clean with soap and water BID, clean buttocks with soap and water, pat dry, apply regular barrier cream to buttocks BID.

Review of the flow sheet for 2/7/22 to 3/8/22 revealed the following dates the wound care had not been performed twice as day as ordered to buttocks and inner thighs, but only one time a day:
2/11/22, 2/12/22, 2/13/22, 2/14/22, 2/14/22, 2/15/22, 2/16/22, 2/17/22, 2/18/22 and 2/20/22.

Left Buttock: Discontinue wound care dated 2/21/22.

The following dates reveal the wound care to the inner thighs was not completed twice a day as ordered by the physician but only one time a day: 2/22/22, 2/23/22, 2/24/22, 2/25/22, 2/26/22, 2/27/22, 2/28/22, 3/1/22, 3/4/22, 3/5/22, 3/6/22 and 3/8/22.

Weights:

Review of the physician orders dated 2/19/22 revealed an order for daily weights.

Review of the Adult Admission Assessment on 2/7/22 revealed a weight of 226 lbs.

Review of the Weight Flow Sheet for the dated 2/7/22 to 3/8/22 revealed a weight of 219 lbs on 2/19/22, 2/22/22 with a weight of 220 and not again until 3/8/22 with a weight of 248.6 lbs.

Review of the medical documentation revealed the patient was not weighed daily as ordered by the physician.

An interview was conducted on 3/10/22 at 2:25 PM with EI # 1 who confirmed the wound care had not been completed twice a day as ordered and the weights were not completed daily per the physician order.

4. PI # 8 was admitted to the facility on 2/9/22 with admitting diagnoses of Congestive Heart Failure (CHF), Muscle Weakness and Chronic Obstructive Pulmonary Disease (COPD).

Review of the physician orders dated 2/10/22 revealed an order for daily weights to be conducted.

Review of the Adult Admission Assessment on 2/9/22 revealed the patient weighed 160 lbs (pounds).

Review of the flow sheet for daily weights with a date range of 2/9/22 to 3/8/22 revealed a weight documented on admission of 160 lbs and no documentation until 2/15/22 with a weight of 162.5 lbs. Further review revealed no other documentation of weights after 2/15/22. The patient was transferred on 2/16/22 to an acute facility.

An interview was conducted on 3/10/22 at 2:35 PM with EI # 1 who confirmed daily weights were not performed per the physician order.

5. PI # 2 was admitted to the facility on 2/10/22 with admitting diagnoses of Muscle Weakness and CHF Exerbation and discharged from the facility on 2/21/22.

Review of the physician orders dated 2/11/22 revealed an order written for daily weights.

Review of the Adult Admission Assessment dated 2/10/22 revealed an initial weight of 228.6 lbs.

Review of the daily weight flow sheet dated 2/10/22 to 3/8/22 revealed the initial weight documented at 228.6 lbs. The next entry on the flow sheet was dated 2/15/22 and the weight was 226.8 lbs. Further observation of the flow sheet revealed an entry for 2/19/22 with a weight of 218.2 lbs, and an entry on 2/20/22 with a weight of 218.2 lbs. No further weights were documented on the flow sheet.

An interview was conducted on 2/10/22 at 2:40 PM with EI # 1, CNO who confirmed the staff failed to weigh the patient daily as ordered by the physician.

6. PI # 4 was admitted to the facility on 2/19/22 with admitting diagnoses of End Stage Renal Disease and Diabetes Mellitis and discharged on 3/1/22.

Review of the physician order dated 2/19/22 revealed an order to weigh daily.

Review of the documentation in the medical record revealed the patient was weighed on 2/19/22, 2/22/22, 2/23/22 and 2/24/22. Further review revealed the patient was not weighed on 2/20/22, 2/21/22 and not weighed after 2/24/22.

Review of the physician orders revealed an order written on 2/20/22 to clean incision to right hip and right thigh with wound cleanser, pat dry, cover with dry dressing Q HS (every night).

Review of the wound care documentation revealed the dressing and cleansing of the wound did not occur to wound # 2 right hip on 2/23/22, 2/24/22 and 2/25/22.

Review of the right thigh wound # 3 revealed the wound care and dressing change was not completed on 2/23/22, 2/24/22 and 2/25/22. Further review of the wound documentation revealed wound # 4 to the right mid thigh and wound # 5 to right inferior thigh was not completed on 2/23/22, 2/24/22, 2/25/22 and 2/26/22.

An interview was conducted on 3/10/22 at 2:30 PM with EI # 1 who confirmed the staff failed to follow the physician order for the dressing changes to each wound Q HS as ordered.

7. PI # 6 was admitted to the facility on 1/12/22 with admitting diagnoses of Chronic Obstructive Pulmonary Disease and Systolic Heart Failure and transferred on 1/20/22.

Review of the Adult Admission Assessment dated 1/12/22 revealed the patient was admitted with a PICC (Peripherally Inserted Central Catheter).

Review of the physician orders revealed an order written on 1/12/22 for Central Venous Line Care.

Review of the SN (Skilled Nurse) documentation in the medical record from admission on 1/12/22 to 1/20/22 when PI # 6 was transferred revealed no documentation the PICC line dressing had been changed weekly per the facility policy.

Review of the physician order dated 1/12/22 revealed an order for daily weights.

Review of the daily weight log documentation revealed the patient was weighed on 1/12/22 and on 1/18/22. The staff failed to perform daily weights as ordered by the physician.

An interview was conducted on 3/10/22 at 2:35 PM with EI # 1 who confirmed the staff failed to change the PICC line dressing weekly while admitted to the facility and the staff failed to ensure the patient was weighed daily as ordered by the physician.

Based on observations, facility policies and procedure, CDC (Centers for Disease Control) and Prevention Guidelines for Hand Hygiene in Health-Care Setting, CDC Clean Hands Count for Patients and interviews with the staff it was determined the facility failed to ensure:

1. Staff performed hand hygiene and wore gloves per hospital policy and per CDC recommendations.

2. Staff wore proper Personal Protective Equipment (PPE) in each Contact Isolation room.

3. Cleaned equipment used in a Contact Precaution patient room to include the scanner on the WOW (Workstation on Wheels) after scanning the patient arm band.

This deficient practice affected 3 of 5 observations of unsampled patients, and had the potential to negatively affect all patients served by the facility.

Findings include:

Facility Policy: Hand Hygiene
Policy Number: 170
Review Date: 2/16/22

Purpose:

To decrease the risk of transmission of infection by appropriate hand hygiene.

Policy:

Every employee will use proper hand hygiene.

Indications for Handwashing and Hand Antisepsis:

a. When hands are visibly dirty or contaminated, wash hands with soap and water.

b. If hands are not visibly soiled, use of a greater then 60% alcohol-based hand rub for routinely decontamination hands is acceptable.

c. Before and after patient contact providing care or treatment and before entering and exiting a patient room or environment.

d. Wash hands after removing gloves.

1. Employees will specifically use soap and water to perform hand hygiene under the following conditions.

C. Taking care of patients on Contact Precautions during periods of outbreak or high volume of cases with spore forming organisms such as C Difficile, norovirus and rotavirus.

Procedure:

Handwashing:

1. Turn on water to a comfortable warm temperature.

2. Moisten hands with soap and water to make a heavy lather.

3. Wash well for a minimum of 20 seconds using a rotary motion and friction.

4. Rinse hands well under running water.

5. Dry hands with a clean paper towel and discard.

6. Turn off faucet with paper towel and discard.

7. If hands are not visibly soiled, use an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hand and fingers, until hands are dry.

Facility Policy: Standard and Transmission-Based Precautions
Policy Number: 200
Review Date: 2/16/22

Purpose:

To provide a safe environment through minimizing the risk of transmission of infection (blood-borne, enteric etc.) Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in the hospital.

Policy:

I. Standard Precautions:

It is the intent of this hospital that all patient blood and body fluids will be considered potentially infectious. Standard precautions will be used to treat all patients...

1. Standard Precautions will apply to contact with blood and body secretions and excretions, except sweat, regardless of whether or not they contain visible blood.

2. All healthcare workers will routinely practice good hand hygiene...and use personal protective equipment (PPE) to prevent skin and mucous membrane exposure when contact with blood and other body fluid is anticipated or possible.

a. Hand hygiene will be performed before beginning work assignment, upon entering a patient room/environment, with each new task, and upon exit of room or task completion before approaching a new patient...

c. PPE: Gloves will be worn when it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious materials...

II. Contact Precautions:

Contact Precautions, in addition to Standard Precautions will be used for patients known or suspected to be infected with epidermiologically important microorganism that can be transmitted by direct contact with the patient or indirect contact with environmental surfaces associated with the patient.

Use Contact Precautions for patients know or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment.

Guidelines:

3. Perform appropriate hand hygiene upon entering and leaving patient room and as other wise needed during patient care.

4. Wear gloves and/or gown as patient care tasks dictate in according with Standard Precautions. When direct contact with the patient or patient's environment is anticipated apply appropriate barrier...

Facility Policy: Management of MDRO's (Multi Drug Resistant Organisms)
Policy Number: 210
Review Date: 2/16/22

II. Management of Patients with MDRO's Infections

1. Patients will be placed in Contact Precautions when infected with MRSA (Methicillin-Resistant Staphylococcus Aureus) or VRE (Vancomycin-Resistant Enterococcus). Contact Precautions for these patients means:

A. Gloves and gowns when coming in contact with the patient or the patient's environment...

C. Remove gloves and gown when leaving the room. Clean hands with waterless hand gel or wash with soap and water.

D. If possible, provide dedicated equipment. If dedicated equipment is not available, clean and disinfect any piece of equipment before use on another patient...

IV. PPE

2. Wear gloves and gown for all direct patient care activities...

CDC and Prevention Guidelines for Hand Hygiene in Health-Care Setting
Last Updated June 25, 2018

When to Perform Hand Hygiene:

Before and after having direct contact with a patient's intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed)

After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings.

After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

After glove removal.

CDC "Clean Hands Count for Patients"

How should your healthcare providers clean their hands?

Using soap and water:
1. Wet their hands with water.
2. Apply an amount of soap recommended by the manufacturer to their hands.
3. Rub their hands together for at least 15 seconds, covering all surfaces of the hands and fingers.
4. Rinse their hands with water and dry with a disposable towel.
5. Use the towel to turn off the faucet.

1. An observation was conducted on 3/8/22 at 12:10 PM to observe medication pass to room 107 B, a contact isolation patient.

During the observation, Employee Identifier (EI) # 3, Registered Nurse (RN) entered the contact isolation room to obtain the blood pressure (BP) of the patient for the medication pass. EI # 3 sanitized hands donned gloves and obtained the blood pressure cuff and placed it on the patient's arm. The BP was taken, the cuff removed and EI # 3 removed gloves and exited the room. EI # 3 failed to sanitize hands after removing gloves and failed to follow the facility policy for donning a gown to perform patient tasks.

EI # 3 then entered the patient room after sanitizing hands, donning gloves and a gown and a mask, with the medication scanner from the medication cart. EI # 3 scanned the patient bracelet and exited the room with the PPE on to ensure the bracelet was scanned. EI # 3 had to repeated the scan so EI # 3 re-entered the room with the same PPE on and rescanned the patient's bracelet. EI # 3 scanned the bracelet again and exited the room wearing the same PPE, scanned the medications and placed in a cup. EI # 3 had a container of water on the medication cart and poured water in a cup wearing the same gloves and gown worn in the patient room. EI # 3 entered the room with the same PPE and administered the medications. EI # 3 removed PPE prior to exiting room, and sanitized hands. EI # 3 placed the scanner on the charger on the medication cart and failed to clean the scanner after being taken into a contact isolation room. EI # 3 then moved to another room with the medication cart and did not clean the cart or the scanner.

An interview was conducted on 3/10/22 at 10:00 AM with EI # 1 Chief Nursing Officer (CNO) who confirmed hand hygiene is to be performed after removing gloves, and the gloves and gown worn in a contact isolation room should be removed prior to leaving the patient room and not worn out in the hallway. She also stated if the medication cart scanner was taken in a contact isolation room it should be cleaned prior to placing back on the cart.

2. An observation was conducted on 3/8/22 at 12:25 PM with EI # 4 Licensed Practical Nurse (LPN) to observe a medication pass in room 122, a contact isolation room.

During the observation EI # 4 obtained the patient medications from the medication cart drawer. EI # 4 sanitized hands and donned gloves, entered the patient room and administered the medications. EI # 4 removed gloves and sanitized hands. EI # 4 was asked what the facility policy was for PPE when entering a contact isolation room. EI # 4 stated "we are to wear gloves and a gown when entering a contact isolation room and I did earlier and I should have this time also and I did not."

An interview was conduced on 3/8/22 at 12:35 PM with EI # 4 who confirmed he/she did not wear a gown into the contact isolation room and should have.



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3. On 3/8/22 at 12:13 PM, an observation of the south unit was made. During the observation, EI # 5, RN, was observed in the hallway for rooms 210-212 wearing gloves, cleaning the vital sign machine. After cleaning the machine, EI # 5 doffed his/her gloves and donned a new pair of gloves without performing hand hygiene. EI # 5 then went into room 211 B with the vital sign machine and assisted another staff member with a patient. EI # 5 exited room 211, doffed gloves, donned a new pair of gloves without performing hand hygiene, and cleaned the vital sign machine with a sani-cloth wipe. EI # 5 then doffed his/her gloves, did not perform hand hygiene, and went to use the computer at the nurses station.

EI # 5 failed to perform hand hygiene after removing gloves 3 times.

In an interview conducted on 3/10/22 at 3:15 PM, EI # 1 confirmed EI # 5 did not follow facility policy for hand hygiene.