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

1. Failing to ensure the implementation of nursing interventions relating to the prevention and/or treatment of skin breakdown for 2 of 6 sampled patients (Patient #2, Patient #1). This included failing to ensure accurate skin assessments were performed, failing to ensure the physician was notified of significant changes including the development and worsening of a pressure wound, failing to ensure orders were obtained prior to the application of wound dressings, failing to provide documentation to indicate orders relating to wound care and relating to turning were consistently implemented. (See findings under A0395)

2. Failing to implement an effective system that ensures the nursing needs of patients are met. This was evidenced by the hospital's implementation of a staffing grid that factors only the number of patients on the unit and not the patient care needs and/or patient acuity. (See findings under A0392)

3. Failing to ensure blood cultures and/or wound cultures were obtained as ordered by the physician for 3 of 6 sampled patients (Patient #2, Patient #1, Patient #4). (See findings under A0395)

Based on record review and interview, the hospital failed to follow their policy and provide written notice of the resolution of a patient's grievances for 2 out 2 grievances submitted by the patient's family (#2). Findings:

Review of the Patient/Family Complaint Form dated 7/3/11 by the family of Patient #2 revealed the grievance was related to the family never being able to speak to a physician, not being able to view x-rays or lab reports, and the family was also concerned with the patient not being able to have anything my mouth.

Review of the second Patient/Family Complaint Form dated 7/17/11 by the family of Patient #2 revealed the grievance was related to the family stating a nurse taking care of their father lied to them about a medication that was administered to the patient.

An interview was conducted with S14Administrator on 01/26/12 at 11 a.m. He could not provide documentation that a letter was sent to the family on the resolutions to their grievances.

Review of the Hospital's policy on Patient/Family Grievance, Policy # I-.1.11, revealed in part,"....The patient/family/representative will be kept informed of all efforts made to resolve their grievance and will receive a written acknowledgement within 5 days of receipt from the Case Manager or DON (Director of Nurses)...If a solution can be reached a written notice will be forwarded to the patient with 10 working days of receipt of the grievance...The patient/family/representative will be informed that the hospital is still working on resolution and a written response is forth coming and will be forwarded to the complainants within 30 days of original receipt of the grievance."

Based on record review and interviews the hospital failed to have performance improvement activities track adverse patient events for 1 out 6 sample patients (#2). Findings:

Review of Patient #2's medical record revealed he was a 76 year old man admitted to the hospital on 06/08/11 for respiratory failure. During to his hospital stay he developed Stage IV pressure ulcers to his right and left buttocks.

Review of the hospital's QAPI (Quality Assurance Performance Improvement) data (June 2011 through present time) revealed no evidence to indicate that the hospital had identified the need to review Patient #2's medical record to determine if the patient's stage IV hospital acquired pressure wounds were avoidable or unavoidable. In addition, there was no indication that the hospital had identified through its QAPI program the need to address deficiencies in nursing services such as 1) the completion of comprehensive skin assessments; 2) immediately notifying the physician/practitioner of significant changes in patient's skin; and 3) wound care nurses writing orders in the absence of discussing with the physician/practitioner.

S3 (Quality Assurance Performance Improvement Nurse) was interviewed on 1/27/12 at 11:15 a.m. S3 confirmed that the hospital failed to review Patient #2's medical record in order to determine if the patient's stage IV hospital acquired pressure wounds were avoidable or unavoidable. In addition, S3 confirmed that there was no indication that the hospital had identified through its QAPI program the need to address deficiencies in nursing services such as 1) the completion of comprehensive skin assessments; 2) immediately notifying the physician/practitioner of significant changes in patient's skin; and 3) wound care nurses writing orders in the absence of discussing with the physician/practitioner.

Based on record review and interview, the hospital failed to implement an effective system that ensures the nursing needs of patients are met. This was evidenced by the hospital's implementation of a staffing grid that factors only the number of patients on the unit and not the patient care needs and/or patient acuity. Deficiencies relating to the completion of comprehensive skin assessments for 1 of 6 sampled patients (Patient #2) and relating to the provision of wound care to 1 of 6 sampled patients (Patient #1) due to the wound care nurse calling in and the floor nurse reporting she did not have time to do the wound care. Findings:

Review of the Staffing Grid presented by the hospital as what the hospital uses to determine nursing staffing needs revealed on the night shift if the census was between 15 and 20 patients, 2 RNs (Registered Nurses) were needed.

Review of the Staffing Pattern Worksheet from 1/17/12 through 1/26/12 revealed the following:
On 1/17/12 there was census of 18 patients and 1 RN was on the night shift,
On 1/18/12 there was a census of 18 and 1 RN worked the night shift,
On 1/20/12 there was a census of 17 and 1 RN worked the night shift.
On 1/23/12, 1/24/12, and 1/26/12 there was a census of 19 and 1 RN worked the night shift.

An interview was conducted with S1DON on 1/27/12 at 11:45 a.m. S1 indicated that she uses a staffing grid to determine the number of nurses needed to work on the patient care unit. S1 indicated that the number of nursing personnel needed is based on patient census and not on the acuity level of the patients on the unit. S1 indicated that she was not aware of an acuity level at LTAC of Slidell. S1 reviewed the staffing grid and confirmed that she was short an RN on the night shifts on 1/17/12, 1/18/12, 1/20/12, 1/23/12, 1/24/12, and 1/26/12.

An interview was conducted with S14Adminstrator on 1/27/12 at 12 p.m. He reported he was aware the hospital was short 1 RN on the night shift.

Patient #2: Medical record review revealed deficiencies relating to the accurate completion of skin assessments from 6/13/11 through 6/16/11 after a stage II wound had been indentified to the patient's buttocks by the wound care nurse.

In an interview on 1/24/12 at 11:05 a.m., the Director of Nursing (S1) reviewed the nursing documentation and confirmed that the nurses failed to ensure the accurate completion of skin assessments from 6/13/11 through 6/16/11.

Patient #1: Medical record review revealed she was 52 year old female admitted in August 2011 to a hospital in Mississippi with Fournier's gangrene. She had a massive infection in her upper left thigh, which was accompanied by multi-organ failure. In November of 2011 she was transferred to a Long Term Acute Care Hospital (LTAC) on a ventilator and then had to be transferred to another acute care hospital for pneumonia and a new vascular access for dialysis. She was transferred after the hospitalization to the present LTAC on 1/11/12. Her current diagnoses include: Diabetes mellitus Type I, Diabetic nephropathy with chronic renal insufficiency with acute renal failure secondary to sepsis syndrome, Gangrene of the left thigh and groin, Status post extensive debridement, history of diverting colostomy because of a Stage 4 sacral pressure ulcer, history of Dysphagia with PEG tube placement, history of stroke with right sided weakness and history of Encephalopathy. She also had a trach and was on a ventilator.

Patient #1 had 3 wounds that were being treated at the hospital. As of 1/23/12 her sacral pressure wound measured 7 cm (centimeters) X 3 cm X 2.4 cm. The wound was classified a Stage IV with moderate serosangeous drainage and tunneling at 12:00 of 1.2 cm. She was on a wound vac and mist therapy for the sacral wound. She also had a Stage IV occipital pressure wound that measured 1 cm X 1 cm X .1 cm. Her last wound was the site of the abscess in her left inner thigh. The measurements were 10 cm X 4.5 cm X.1cm.

1. Review of the Physician Orders for dated 1/10/12 revealed the Skin and wound care order was:
1. Turn q (every) 2 hours side to side
2. Float heels
3. Occipital Stage IV - clean with N/S (normal saline). Puracol and cover and change MWF (Monday, Wednesday, and Friday).
4. Sacral Stage IV- clean with N/S. Santyl cover with N/S moist gauze and form dressing daily.
5. L (left) inner thigh- perineum abscess-clean with N/S. Puracol and cover with x 2 border gauze. Change MWF.
6. Mist sacral MWF.

Review of the Treatment Administration Record (TAR) dated 01/18/12 revealed the Sacral Stage IV wound care was not done and the mist therapy to the sacral wound was not done. In the documentation box for 1/18, there were initials in the box circled with the handwritten documentation next to the circle with "not done" written beside the circle. Review of the nurses notes for 1/18/12 revealed no documentation why the treatment was not performed.
Review of the Patient Acuity Staffing Report dated 1/18/12 revealed handwritten under Staffing Issues/Concerns, "No wound care nurse."

An interview was conducted with S1DON on 1/25/12 at 2:30 p.m. S1 reviewed the TAR dated 1/18/12. S1 stated she remembered why the treatment was not done that day. She went on to report the nurse that had been assigned to Patient #1 on 1/18/12 told her that she was too busy and was unable to do the wound care on that day. She also reported the wound care nurse had call in and there was no wound care nurse working that day.

Based on record review, observation, and interview, the Registered Nurse failed to ensure the supervision and evaluation of care provided to patients as evidenced by:

1. Failing to ensure the implementation of nursing interventions relating to the prevention and/or treatment of skin breakdown for 2 of 6 sampled patients (Patient #2, Patient #1). This included failing to ensure accurate skin assessments were performed, failing to ensure the physician was notified of significant changes including the development and worsening of a pressure wound, failing to ensure orders were obtained prior to the application of wound dressings, failing to provide documentation to indicate orders relating to wound care and relating to turning were consistently implemented. Findings:

Patient #2: Medical record review revealed Patient #2 was admitted to LTAC of Slidell (long term acute care hospital) on 6/07/11 at 11:00 p.m. Review of the History & Physical dated 6/08/11 at 9:50 p.m. revealed Patient #2's "History of Present Illness" as "76 y/o male (with) hx (history) of COPD (with) recurrent right pleural effusions. He has required multiple thoracenteses in May to relieve SOB. Finally it was decided that the patient would require VATS. Pt had acute resp failure after surgery". Documentation on the History & Physical revealed Patient #2's "Past Medical History" as "COPD, HTN, DM, Hyperlipidemia, Anxiety, DJD, Gout, Dysphagia". Documentation on the History & Physical revealed the "Impression/Diagnosis" as 1-Acute Resp Failure, 2-Right pleural effusion verses atelectasis, 3-DM II, 4-Malnutrition, 5-Anemia, 6-COPD, 7-Hx of alcohol use, 8-Dysphagia, 9-Aspiration Pneumonitis. Documentation on the History & Physical revealed Patient #2's "Skin" as "Stage I decubitus to (right) heel, small opening to (right) posterior chest wall 2cm long & 4.5cm deep draining serous fluid". There was no documentation on the History & Physical to indicate that Patient #2 has any skin abnormalities to his buttocks or sacral area.

Review of the Initial Nursing Assessment dated 6/08/11 at 6:00 a.m. revealed under the section of "Wound Assessment" that Patient #2 had a status post thoracentesis wound located at the right lower posterior chest (4.5cm in depth) with serous drainage, and some redness on his left heel, and a Peg tube site. There was no documentation on the Initial Nursing Assessment to indicate that Patient #2 had any skin abnormalities on his buttocks or sacral area at the time of admission.

Review of the "Physical Therapy Initial Evaluation/Physician's Orders" dated 6/09/11 at 11:25 a.m. and the "Occupational Therapy Initial Evaluation/Physician's Orders" dated 6/08/11 at 1:35 p.m. revealed Patient #2's was unable to do any standing and was dependant for all activities of daily living upon admission. Documentation revealed little change in Patient #2's functional status throughout his hospitalization. Documentation revealed that Patient #2 had diminished cognitive skills.

Documentation on the "Daily Nursing Assessment" revealed that Patient #2 was confused, disoriented, and had impaired judgement throughout his hospitalization. Documentation revealed Patient #2 had an indwelling foley catheter and was incontinent of bowels throughout his hospitalization. Review of the documented skin assessments on the "Daily Nursing Assessment" (documented by the nurses providing care to Patient #2) revealed the following in relation to Patient #2's skin on the buttocks and sacral area for the dates of 6/09/11 thru 6/21/11:
? 6/09/11- Documentation for the night shift that began on 6/09/11 revealed that Patient #2 had a pressure area on his buttocks that was red in color with no odor and no exudates and open to air. There was no documentation to indicate the skin was broken or the staging or measurements of the wound.
? 6/10/11- There was no documentation addressing the condition of Patient #2's skin on the buttocks or sacral area for this day.
? 6/11/11- There was no documentation addressing the condition of Patient #2's skin on the buttocks or sacral area for this day.
? 6/12/11- There was no documentation addressing the condition of Patient #2's skin on the buttocks or sacral area for this day.
? 6/13/11- There was no documentation addressing the condition of Patient #2's skin on the buttocks or sacral area for this day.
? 6/ 14/11- There was no documentation addressing the condition of Patient #2's skin on the buttocks or sacral area for this day.
? 6/15/11- There was no documentation addressing the condition of Patient #2's skin on the buttocks or sacral area for this day.
? 6/16/11- There was no documentation addressing the condition of Patient #2's skin on the buttocks or sacral area for this day.
? 6/17/11- Documentation for the day shift revealed Patient #2's buttocks were red with the surrounding tissue within normal limits. Documentation for the night shift that began on 6/17/11 revealed Patient #2's buttocks were red with the surrounding tissue within normal limits. There was no documentation to indicate the description of the area to include the measurements of the reddened area.
? 6/18/11- Documentation for the day shift revealed Patient #2 had a Stage II wound on the buttocks that was red pink in color with no odor and no exudates with the surrounding tissue being pink. Documentation revealed the stage II wound was open to air on the day shift. Documentation for the night shift that began on 6/18/11 revealed Patient #2's buttocks were red with no odor and no exudate. Documentation revealed a duoderm dressing was removed and an optifoam dressing was applied on the night shift to the patient's buttocks area. There was no documentation to indicate the measurements of the stage II wound or the reddened area for either shift on this day. There were no orders to apply an optifoam dressing to Patient #2's buttocks.
? 6/19/11- Documentation for the day shift revealed Patient #2 had a Stage II wound on the buttocks that was pink red in color with no odor and no exudates with the surrounding tissue being pink. Documentation revealed a dressing was intact. Documentation for the night shift that began on 6/19/11 revealed Patient #2 had a Stage II wound on the buttocks that was pink red in color with no odor and no exudate. Documentation revealed a dressing was intact. There was no documentation to indicate the measurements of the stage II wound or the reddened area for either shift on this day.
? 6/20/11- Documentation for the day shift revealed a dressing to Patient #2's buttocks was dry and intact. Documentation for the night shift that began on 6/20/11 revealed a dressing to Patient #2's buttocks was dry and intact.
? 6/21/11- Documentation for the day shift revealed a dressing to Patient #2's buttocks was dry and intact. Documentation for the night shift that began on 6/20/11 revealed a dressing to Patient #2's buttocks was dry and intact.

Review of the physician orders relating to skin care to the buttocks revealed the following:
? Orders dated 6/08/11 at 3:00 p.m. to "turn q 2 (hours)", "float heels while in bed" and "apply Calazime to buttocks q day & (after) each incontinent episode".

Documentation on the "Daily Wound Care Note" and the "Treatment Administration Record" (documented by the wound care nurse) revealed the following in relation to Patient #2's skin on the buttocks and sacral area:
? 6/08/11- Documentation revealed no skin abnormalities to the buttocks or sacral area of Patient #2 for this day.
? 6/13/11- Documentation revealed a wound measuring 1.4cm X 1.6cm and a wound measuring 1.5cm X .6cm was noted to Patient #2's Left buttock and an area measuring .4cm X .5cm was noted to Patient #2's Right buttock. Documentation indicated friction as the source of the wounds. Documentation revealed the wound bed color was red with scant drainage. Pictures of the wounds were in the medical record. Documentation revealed "covered (with) hydrocolloid. Encouraged & reminded Pt to stay on his (Left) or (Right) side. Propped with pillows. Calazime applied to buttocks". Documentation under the section of "Treatment" revealed "Preventative Skin Care: 1) Calazime to buttocks q day/PRN, 2) Turn q 2 hours, 3) Float heels while in bed". Documentation revealed the wound care treatment to the buttocks included "hydrocolloid to (Left) & (Right) buttock friction areas. (Change) q 3 - 5 (days) PRN". Review of the medical record revealed no orders for the hydrocolloid treatment that was initiated on 6/13/11.
? 6/14/11- Documentation indicated the hydrocolloid dressing was intact to the buttocks. There was no description of the wounds documented for this day. Review of the medical record revealed no orders for the hydrocolloid treatment for this day.
? 6/15/11- Documentation indicated the hydrocolloid dressing was intact to the buttocks. There was no description of the wounds documented for this day. Review of the medical record revealed no orders for the hydrocolloid treatment for this day.
? 6/16/11- Documentation indicated the hydrocolloid dressing was applied to the buttocks. There was no description of the wounds documented for this day. Review of the medical record revealed no orders for the hydrocolloid treatment for this day.
? 6/17/11- Documentation indicated the hydrocolloid dressing was intact to the buttocks. There was no description of the wounds documented for this day. Review of the medical record revealed no orders for the hydrocolloid treatment for this day.
? 6/18/11- Documentation indicated the hydrocolloid dressing was applied to the buttocks. There was no description of the wounds documented for this day. Review of the medical record revealed no orders for the hydrocolloid treatment for this day.
? 6/19/11- Documentation indicated the hydrocolloid dressing was applied to the buttocks. There was no description of the wounds documented for this day. Review of the medical record revealed no orders for the hydrocolloid treatment for this day.
? 6/20/11- Documentation revealed a wound measuring 8cm X 3.6cm (depth unknown due to the wound bed color documented as being dark brown-black) to Patient #2's Left buttock and a wound measuring 8cm X 4.7cm (depth unknown due to the wound bed color documented as being dark brown-black) to Patient #2's Right buttock. Pictures of the wounds were in the medical record and revealed a significant change from the picture taken on 6/13/11. Documentation revealed "covered (with) hydrocolloid. Encouraged & reminded Pt to stay on his (Left) or (Right) side. Propped with pillows. Calazime applied to buttocks". Documentation under the section of "Treatment" revealed "Preventative Skin Care" included Turn q 2 hours and Float heels while in bed. Documentation revealed the wound care treatment to the buttocks included "Bil buttock friction areas hydrocolloid (change) PRN" and "Mist therapy to Bil buttock friction areas M,W,F".

Documentation in the medical record revealed Patient #2's wounds on his left and right buttock progressed throughout his hospitalization. Documentation revealed inconsistencies in relation to the physicians order to turn Patient #2 every 2 hours. Review of the "Daily Nursing Assessment" forms revealed that documentation of the turning schedule for Patient #2 was under a section titled "Hourly Record". Documentation under this "Hourly Record" section was "Turn q 2 (B, L, R, S-Self). (In an interview on 1/25/12 at 11:00 a.m., the Director of Nursing reported the B stands for Back, the L stands for Left, and the R stands for Right. The Director of Nursing reported the nurses should have ensured that Patient #2 was turned every 2 hours and documented the side Patient #2 was turned to in order to track which side Patient #2 was recently on to ensure he was turned to the appropriate side.) Review of the documentation corresponding to the turning schedule revealed the following inconsistencies from 6/10/11 through 6/20/11 (time stage IV wounds were identified on Patient #2's buttocks):
? 06/10/11- check marks were documented for the times of 7:00 p.m., 9:00 p.m., and 11:00 p.m. (no additional documentation was found in the nursing notes to indicate the side Patient #2 was turned on between 7:00 p.m. and 11:00 p.m.)
? 06/11/11-check marks were documented for the times of 1:00 a.m., 3:00 a.m., 5:00 a.m., 7:00 p.m., 9:00 p.m., and 11:00 p.m. (no additional documentation was found in the nursing notes to indicate the side Patient #2 was turned on between 1:00 a.m. and 5:00 a.m. and between 7:00 p.m. and 11:00 p.m.)
? 06/12/11-check marks were documented for the times of 1:00 a.m., 7:00 p.m., 9:00 p.m., and 11:00 p.m. (no additional documentation was found in the nursing notes to indicate the side Patient #2 was turned on at 1:00 a.m. and between 7:00 p.m. and 11:00 p.m.)
? 06/13/11-Self documented from 7:00 p.m. through 5:00 a.m. on 6/14/11. (Nursing documentation under safety assessment indicated that Patient #2's risk factors included confused/disoriented/impaired judgment and that Patient #2 was dependant for transfer. No documentation was identified to indicate that Patient #2 was turned every 2 hours as ordered from 7:00 p.m. through 5:00 a.m.)
? 06/14/11-Self documented from 7:00 p.m. through 5:00 a.m. on 6/15/11. (Nursing documentation under safety assessment indicated that Patient #2 ' s risk factors included confused/disoriented/impaired judgment and that Patient #2 was dependant for transfer. No documentation was identified to indicate that Patient #2 was turned every 2 hours as ordered from 7:00 p.m. through 5:00 a.m.)
? 06/15/11-Self documented from 7:00 p.m. through 5:00 a.m. on 6/16/11. (Nursing documentation under safety assessment indicated that Patient #2's risk factors included confused/disoriented/impaired judgment. No documentation was identified to indicate that Patient #2 was turned every 2 hours as ordered.)
? 06/16/11-check marks were documented for the times of 7:00 p.m., 9:00 p.m., and 11:00 p.m. (Nursing documentation under safety assessment indicated that Patient #2's risk factors included confused/disoriented/impaired judgment and that Patient #2 was dependant for transfer. No documentation was identified to indicate which side Patient #2 was turned on every 2 hours as ordered from 7:00 p.m. through 11:00 p.m.)
? 06/18/11-refused and offered documented from 6:00 a.m. through 5:00 p.m. (Nursing documentation under safety assessment indicated that Patient #2's risk factors included confused/disoriented/impaired judgment. No documentation was identified to indicate that continuous efforts were made to turn Patient #2 every 2 hours as ordered on this date.)
? 06/19/11-refused documented at 6:00 a.m. with dash marks entered during remainder of this day. (Nursing documentation under safety assessment indicated that Patient #2's risk factors included confused/disoriented/impaired judgment. Documentation indicated "Pt had refused to be turned all shift yesterday". Documentation indicated Patient #2 was unable to be turned during a portion of the day shift due to low oxygenation levels. Documentation revealed Pt. was refusing to turn to side at other times during shift.)

Review of the physician orders relating to skin care to the buttocks revealed the following:
? Orders dated 6/20/11 at 10:10 a.m. to "Discontinue Calazime to Bil buttocks", "hydrocolloid to necrotic friction areas bil buttock (change) PRN", "Turn side to side only q 2 (hours), "Start Mist therapy today & Cont M,W,F".
? Orders dated 6/29/11 at 12:30 p.m. to "Discontinue hydrocolloid to buttock. Start Santyl daily. Cover with N/S moist gauze & foam dressing".
? Orders dated 7/07/11 at 3:45 p.m. for "(name of surgical center) to call for appt for debridement (with) (name of physician) of bilateral buttocks. Outpatient-return same day".
? Orders dated 7/11/11 at 9:45 a.m. for "Debridement orders: Wed 7/13/11 at 7:00 at (name of surgical center) for bilateral buttocks, arrange transportation (with) ambulance".
? Orders dated 7/12/11 at 11:30 a.m. to "Send pt to (name of surgical center) for 0900 on Wed 7/13/11" for Excision & debridement of (bilateral) buttocks.
? Orders dated 7/13/11 at 12:30 p.m. to "monitor bil buttocks X 3-4 for drainage", "N/S wet>dry dressing X 24 if needs (changed)", and "start Santyl 7/14/11. Cover (with) N/S moist gauze & dress (with) Optifoam daily & PRN".
? Orders dated 7/19/11 (untimed) for "Need tissue culture done by (name of surgeon) during I & D last week".

Documentation in the medical record revealed that the wounds to Patient #2's buttocks continued to progress during his hospitalization. Documentation revealed Mist Therapy and Santyl was administered to Patient #2's wounds. Documentation revealed the wounds were "cross-hatched" by the wound care nurse on 6/29/11. Documentation revealed Patient #2 was transported to a surgical center where a debridement of the wounds was done on 7/13/11. Review of the medical record revealed no documentation to indicate the physician was notified on 6/13/11 of the development of the stage II pressure wound after the wound care nurse identified the wound and no documentation to indicate the physician was immediately notified of the progression of the stage II wound to a stage IV wound identified by the wound care nurse on 6/20/11.

In an interview on 1/24/12 at 11:05 a.m., the Director of Nursing (S1) reviewed the Initial Nursing Assessment and confirmed there was no documentation on the initial nursing assessment to indicate that Patient #2 had any skin abnormalities to the buttocks or sacral area. S1 reviewed the medical record including the nursing notes and reported the first documentation of any abnormalities to Patient #2's buttocks or sacral area was entered by S6 (Licensed Practical Nurse) on the night shift that began on 6/09/11 at 6:00 p.m. through 6/10/11 at 6:30 a.m. S1 reported S6's documentation revealed Patient #2 had a pressure area to buttocks that was reddened and the surrounding skin is within normal limits. S1 reviewed the nursing notes and reported the day shift nurse S8 (Licensed Practical Nurse) documented Patient #2's bottom was red with the surrounding tissue being within normal limits on the day shift that began on 6/10/11 at 6:00 a.m. S1 reviewed the nursing notes and reported there was no documentation addressing the condition of Patient #2's buttocks or sacral area on the night shifts from 6/10/11 through 6/16/11 or the day shifts from 6/11/11 through 6/16/11. S1 reviewed the nursing notes and reported S9 (Registered Nurse) documented Patient #2's buttock was red with no odor or exudate with surrounding skin being within normal limits on the day shift on 6/17/11 and S10 (Registered Nurse) documented Patient #2's buttock was red with no odor or exudates with surrounding skin being within normal limits on the night shift that began on 6/17/11. S1 reviewed the nursing notes and reported S12 (Registered Nurse) documented on the day shift on 6/18/11 that a stage II wound was noted to Patient #2's buttocks with the wound being red pink in color with no odor or exudates with surrounding tissue pink and open to air. S1 reported S10 (Registered Nurse) documented on the night shift that began on 6/18/11 that Patient #2 had a pressure wound to buttocks that was red with no odor or exudates with surrounding tissue intact. S1 reported S10 documented that he changed duoderm dressing with optifoam dressing. S1 reported there were no measurements of the stage II wound on 6/18/11. S1 reported there were no orders to apply the duoderm dressing that was documented as being changed by S10 on 6/18/11. S1 reported that documentation on the "Treatment Administration Record" indicated that a hydrocolloid dressing was placed on Patient #2's buttocks on 6/13/11 and remained on until changed with another hydrocolloid dressing on 6/16/11 which remained on Patient #2's buttocks until changed with another hydrocolloid dressing on 6/20/11. S1 reported there were no orders to place the hydrocolloid dressing on Patient #2 until 6/20/11. S1 reported 12 (Registered Nurse) documented on the day shift on 6/19/11 that Patient #2 had a stage II to buttocks (no measurements of wound) pink red in color no odor no exudates, dressing intact surrounding skin is pink. S1 reported S10 (Registered Nurse) documented on the night shift on 6/19/11 that Patient #2 had a stage II (no measurements of wound) pink red in color no odor or exudates, dressing intact, surrounding tissue is pink.

S4 (Certified Wound Specialist) was interviewed on 1/23/12 at 2:00 p.m. S4 reported that she is the hospital's wound care nurse. S4 reviewed the medical record of Patient #2. S4 reported that she initially assessed Patient #2's skin on 6/08/11 at 1:00 p.m. When asked about the skin on Patient #2's buttocks and sacral area at the time of her initial assessment on 6/08/11, S4 reported there were no abnormalities to Patient #2's buttocks or sacral area on 6/08/11. When asked about Patient #2's cognitive status and functional status, S4 indicated that Patient #2 was alert but confused and required assistance with activities of daily living. When asked about Patient #2's ability to turn self, S4 indicated that Patient #2 required assistance with turning due to his cognitive and mobility impairments. S4 reported Patient #2 was resistive to turning and indicated that he only wanted to lie on his back. S4 reported Patient #2 would be turned on his side and would then work himself back to laying on his back. S4 reported that measures to prevent skin breakdown to the buttocks and sacral area included a skin barrier cream and relieving pressure by turning every 2 hours. S4 reported that she first identified pressure areas to Patient #2's buttocks on 6/13/11. S4 reported there was a deep tissue injury on Patient #2's right buttock that appeared as a purple bruise with intact skin and two stage II wounds on Patient #2's left buttock with one measuring ? cm X ? cm and the other measuring 1 ? cm X 1 ? cm. When asked if the physician was notified of the identified change in Patient #2's skin on 6/13/11, S4 reported that she could not recall if the physician was notified on 6/13/11 and reported there was no documentation to indicate that the physician was notified. S4 reported that she added Hydrocolloid dressings to be applied to the buttocks with the Hydrocolloid dressings being changed every 3 to 5 days. S4 reported the Hydrocolloid dressing is used to pad the skin and protect the skin from feces and/or urine. When asked if there were any physician orders for the use of the Hydrocolloid dressings, S4 reported that there were no physician orders for the use of the Hydrocolloid dressings at the time of first placing them on Patient #2. S4 reported that the first orders for the use of Hydrocolloid dressings were on 6/20/11. S4 reported the Hydrocolloid dressings were applied to Patient #2's buttocks from 6/13/11 through 6/20/11 without a physicians order. S4 indicated that she noticed a significant breakdown with Patient #2's buttocks during a skin assessment on 6/20/11. S4 reported the wounds were significantly larger with the wound on the right buttock measuring 8 cm X 4.7 cm with the depth unknown as necrotic tissue was noted in the wound bed and the wound on the left buttock measuring 8 cm X 3.6 cm with the depth unknown as necrotic tissue was noted in the wound bed. When asked if Patient #2's physician (S16 or S5) was notified on 6/20/11 of this change in Patient #2's skin, S4 reported that she could not recall if S16 or S5 was notified on 6/20/11. S4 reported she did know S13 (Medical Director) was notified of this change during the weekly staffing meeting conducted by the hospital's Medical Director (S13) on 6/22/11. S4 reported wound care orders on 6/20/11 included discontinuing the Calazime and to use Hydrocolloid dressings. S4 confirmed that the Hydrocolloid dressings were initially applied to Patient #2's buttocks on 6/13/11 in the absence of a signed physicians order. S4 reported wound care orders on 6/20/11 included turning the patient from side to side every 2 hours and starting Mist therapy. S4 indicated the mist therapy helps to clean the wound bed and stimulate tissue growth. S4 reported the Hydrocolloid dressings were discontinued on 6/29/11 and Santyl with saline gauze & foam dressings were started. S4 reported the wound bed was crosshatched on 6/29/11 using supplies from a sterile kit which included gloves and a scalpel. S4 indicated that Patient #2 was sent to the vascular surgeon's office for wound debridement on 7/13/11 and returned to the hospital immediately following the procedure. When asked about the orders (written by S17) dated 7/19/11 that read "Need tissue culture done by (name of surgeon) during I & D last week", S4 reported that she could not provide any documentation to indicate the tissue culture of the wound had been done. S4 reported there was no documentation to indicate the nursing staff had followed up on the order as there was no indication the ordering physician (S17) was notified of failing to ensure the order was followed.

S6 (Licensed Practical Nurse) was interviewed on 1/26/12 at 1:15 p.m. S6 reviewed the medical record of Patient #2 and reported her initial contact with Patient #2 was on 6/08/11. S6 reported she worked as a wound care nurse during the time Patient #2 was hospitalized at LTAC of Slidell and remained a wound care nurse until October of 2011. S6 reported she has worked as a LPN primarily on the night shift since October of 2011. S6 reported that her move from wound care nurse to LPN was a result of her request to no longer work as a wound care nurse. When asked to explain, S6 reported she felt overwhelmed as a wound care nurse because she felt the primary nurses assigned to the patients on the units and the nursing assistants on the unit relied too much on the wound care nurse. S6 reported that she felt the unit was short staffed much of the time and contributed the short staffing to the reason why the nurses rely too much on the wound care nurse to assess and care for all wounds. S6 reported the hospital staffs based on number of patients and not based on the acuity level of patients. S6 reported that she would often have a difficult time finding someone to assist her with turning and/or repositioning patients who had wounds. S6 reported that she could not recall any specific instances though. When asked about the condition of Patient #2's buttocks, S6 reported that Patient #2 did not have any skin abnormalities to his buttocks at the time of her initial assessment on 6/08/11. S6 reported she first identified friction areas on Patient #2's buttocks on 6/13/11. S6 indicated that she documented the characteristics of the wound and wrote wound care orders including the use of Hydrocolloid dressings on the wound care record. When asked if she notified Patient #2's physician of the newly identified pressure areas to Patient #2's buttocks, S6 reported that she did not notify the physician. When asked if she obtained orders from the physician for the use of Hydrocolloid dressings, S6 reported that she did not obtain the orders from the physician. S6 reported the wound care nurse writes the order and the physician signs the order the next time they come to the hospital. When asked why the physician is not immediately notified of significant changes in patients skin such as the development of or worsening of a pressure sore, S6 reported the physicians are notified when they come to the hospital and look at the pictures of the wounds that are placed in the medical record.

S16 (Medical Doctor) was interviewed on 1/25/12 at 1:40 p.m. S16 reviewed the medical record of Patient #2 and reported that she shared the care of Patient #2 with (S5-Medical Doctor). S16 reported her initial contact with Patient #2 was on 6/08/11. S16 reported she conducted a history & physical evaluation on Patient #2 on 6/08/11. S16 indicated that Patient #2 had significant medical problems and was in poor health at the time of his admission to LTAC of Slidell. When asked about the condition of Patient #2's buttocks, S16 reviewed the medical record and reported there was no documentation to indicate that her (S16) or her partner (S5) had been notified on 6/13/11 of the development of the pressure wound to the buttocks that was identified on 6/13/11 or immediately notified of the progression of the Patient #2's pressure wounds on his buttocks. S16 indicated that she would have expected to have been notified at the time the skin initially broke down on 6/13/11 and would have expected to have been immediately notified when the wound was found to have progressed to a stage IV wound on 6/20/11. After reviewing the medical record, S16 indicated that she did not recall being immediately notified of the pressure wounds on either occasion and did not see where her partner (S5) had been immediately notified.

The hospital approved policy/procedure titled "Goal Documentation" was reviewed. The policy/procedure documents "Through utilization of the individualized nursing care plan, daily documentation inclusive of a systems review, level of tolerance, and level of compliance with rehabilitation and nursing goals, will be addressed. This will include: A. The physical/emotional status, B. The functional status, C. The educational and treatment goals. And will be in compliance with the medical treatment of the patient. Any change in patient status or outcome will be addressed in a progress note for that day. Any apparent change in physiological status of the patient warrants a complete reassessment by a registered nurse and will be reported to the physician in a timely manner".

The hospital approved policy/procedure titled "Patient Care Documentation" was reviewed. The policy/procedure documents under the section of "Shift Assessment/Notes/Interventions/Evaluation" that "the RN and/or LPN will perform and document a total patient reassessment minimally once each shift. Whenever the patient's condition changes, a reassessment will be documented. The RN and/or LPN must document evaluations in an ongoing fashion (as they occur and/or after they occur). The LPN must notify the RN of abnormal findings and deterioration in the patient's condition for assessment, physician notification (if applicable), and evaluation of interventions". The policy/procedure also documents "Integumentary-indicate site of wound beside the word 'wound'. Describe wound condition in Notes/Interventions section".

The hospital approved policy/procedure titled "Nursing Documentation Guidelines" was reviewed. The policy/procedure documents "A Registered Nurse shall be responsible for completing the initial patient assessment. The RN must identify problems, measurable and objective goals and interventions for the patient". The policy/procedure further documents "For changes in patient condition, the RN must be notified for assessment, physician notification (if applicable), and evaluation of interventions. This is to be documented in patient's daily record and communicated to the other disciplines involved in the patient's care".

Patient #1: Medical record review revealed the patient was 52 year old female admitted in August 2011 to a hospital in Mississippi with Fournier's gangrene. She had a massive infection in her upper left thigh, which was accompanied by multi-organ failure. In November of 2011 she was transferred to a Long Term Acute Care Hospital (LTAC) on a ventilator and then had to be transferred to another acute care hospital for pneumonia and a new vascular access for dialysis. She was transferred after the hospitalization to the present LTAC on 1/11/12. Her current diagnoses include: Diabetes mellitus Type I, Diabetic nephropathy with chronic renal insufficiency with acute renal failure secondary to sepsis syndrome, Gangrene of the left thigh and groin, Status post extensive debridement, history of diverting colostomy because of a Stage 4 sacral pressure ulcer, history of Dysphagia with PEG tube placement, history of stroke with right sided weakness and history of Encephalopathy. She had a trach and was on a ventilator.

Patient #1 had 3 wounds that were being treated at the hospital. As of 1/23/12 her sacral pressure wound measured 7 cm (centimeters) X 3 cm X 2.4 cm. The wound was classified a Stage IV with moderate serosangeous drainage and tunneling a

Based on record review and interview, the hospital failed to ensure all orders that were documented in the medical record and carried out by the nursing staff were authorized by a physician and/or practitioner prior to writing a verbal order. This was noted in the medical records of 2 of 6 sampled patients reviewed (Patient 2 and Patient #6). Findings:

Patient #2: Medical record review revealed Patient #2 was admitted to LTAC of Slidell (long term acute care hospital) on 6/07/11 at 11:00 p.m. Documentation on the "Daily Wound Care Note" and the "Treatment Administration Record" (documented by the wound care nurse) revealed the following in relation to Patient #2's skin on the buttocks and sacral area:
? 6/13/11- Documentation revealed a wound measuring 1.4cm X 1.6cm and a wound measuring 1.5cm X .6cm was noted to Patient #2's Left buttock and an area measuring .4cm X .5cm was noted to Patient #2's Right buttock. Documentation indicated friction as the source of the wounds. Documentation revealed the wound bed color was red with scant drainage. Pictures of the wounds were in the medical record. Documentation revealed "covered (with) hydrocolloid. Encouraged & reminded Pt to stay on his (Left) or (Right) side. Propped with pillows. Calazime applied to buttocks". Documentation under the section of "Treatment" revealed "Preventative Skin Care: 1) Calazime to buttocks q day/PRN, 2) Turn q 2 hours, 3) Float heels while in bed". Documentation revealed the wound care treatment to the buttocks included "hydrocolloid to (Left) & (Right) buttock friction areas. (Change) q 3 - 5 (days) PRN". Review of the medical record revealed no orders for the hydrocolloid treatment that was initiated on 6/13/11.
? 6/14/11- Documentation indicated the hydrocolloid dressing was intact to the buttocks. There was no description of the wounds documented for this day. Review of the medical record revealed no orders for the hydrocolloid treatment for this day.
? 6/15/11- Documentation indicated the hydrocolloid dressing was intact to the buttocks. There was no description of the wounds documented for this day. Review of the medical record revealed no orders for the hydrocolloid treatment for this day.
? 6/16/11- Documentation indicated the hydrocolloid dressing was applied to the buttocks. There was no description of the wounds documented for this day. Review of the medical record revealed no orders for the hydrocolloid treatment for this day.
? 6/17/11- Documentation indicated the hydrocolloid dressing was intact to the buttocks. There was no description of the wounds documented for this day. Review of the medical record revealed no orders for the hydrocolloid treatment for this day.
? 6/18/11- Documentation indicated the hydrocolloid dressing was applied to the buttocks. There was no description of the wounds documented for this day. Review of the medical record revealed no orders for the hydrocolloid treatment for this day.
? 6/19/11- Documentation indicated the hydrocolloid dressing was applied to the buttocks. There was no description of the wounds documented for this day. Review of the medical record revealed no orders for the hydrocolloid treatment for this day.
? 6/20/11- Documentation revealed a wound measuring 8cm X 3.6cm (depth unknown due to the wound bed color documented as being dark brown-black) to Patient #2's Left buttock and a wound measuring 8cm X 4.7cm (depth unknown due to the wound bed color documented as being dark brown-black) to Patient #2's Right buttock. Pictures of the wounds were in the medical record and revealed a significant change from the picture taken on 6/13/11. Documentation revealed "covered (with) hydrocolloid. Encouraged & reminded Pt to stay on his (Left) or (Right) side. Propped with pillows. Calazime applied to buttocks". Documentation under the section of "Treatment" revealed "Preventative Skin Care" included Turn q 2 hours and Float heels while in bed. Documentation revealed the wound care treatment to the buttocks included "Bil buttock friction areas hydrocolloid (change) PRN" and "Mist therapy to Bil buttock friction areas M,W,F".

Review of the physician orders relating to skin care to the buttocks revealed orders dated 6/20/11 at 10:10 a.m. to "Discontinue Calazime to Bil buttocks", "hydrocolloid to necrotic friction areas bil buttock (change) PRN", "Turn side to side only q 2 (hours), "Start Mist therapy today & Cont M,W,F". There was no documentation in the medical record to indicate the physician/practitioner authorized the use Hydrocolloid dressings to Patient #2's buttocks prior to 6/20/11.

S4 (Certified Wound Specialist) was interviewed on 1/23/12 at 2:00 p.m. S4 reported that she first identified pressure areas to Patient #2's buttocks on 6/13/11. S4 reported there was a deep tissue injury on Patient #2's right buttock that appeared as a purple bruise with intact skin and two stage II wounds on Patient #2's left buttock with one measuring ? cm X ? cm and the other measuring 1 ? cm X 1 ? cm. S4 reported that she added Hydrocolloid dressings to be applied to the buttocks with the Hydrocolloid dressings being changed every 3 to 5 days. When asked if there were any physician orders for the use of the Hydrocolloid dressings, S4 reported that there were no physician orders for the use of the Hydrocolloid dressings at the time of first placing them on Patient #2. S4 reported that the first orders for the use of Hydrocolloid dressings were on 6/20/11. S4 reported the Hydrocolloid dressings were applied to Patient #2's buttocks from 6/13/11 through 6/20/11 without a physicians order.

S6 (Licensed Practical Nurse) was interviewed on 1/26/12 at 1:15 p.m. S6 reviewed the medical record of Patient #2 and reported her initial contact with Patient #2 was on 6/08/11. S6 reported she worked as a wound care nurse during the time Patient #2 was hospitalized at LTAC of Slidell and remained a wound care nurse until October of 2011. S6 reported she has worked as a LPN primarily on the night shift since October of 2011. When asked about the condition of Patient #2's buttocks, S6 reported that Patient #2 did not have any skin abnormalities to his buttocks at the time of her initial assessment on 6/08/11. S6 reported she first identified friction areas on Patient #2's buttocks on 6/13/11. S6 indicated that she documented the characteristics of the wound and wrote wound care orders including the use of Hydrocolloid dressings on the wound care record. When asked if she notified Patient #2's physician of the newly identified pressure areas to Patient #2's buttocks, S6 reported that she did not notify the physician. When asked if she obtained orders from the physician for the use of Hydrocolloid dressings, S6 reported that she did not obtain the orders from the physician. S6 reported the wound care nurse writes the order and the physician signs the order the next time they come to the hospital. When asked why the physician is not immediately notified of significant changes in patients skin such as the development of or worsening of a pressure sore, S6 reported the physicians are notified when they come to the hospital and look at the pictures of the wounds that are placed in the medical record.

S16 (Medical Doctor) was interviewed on 1/25/12 at 1:40 p.m. S16 reviewed the medical record of Patient #2 and reported that she shared the care of Patient #2 with (S5-Medical Doctor). S16 reported her initial contact with Patient #2 was on 6/08/11. S16 reported she conducted a history & physical evaluation on Patient #2 on 6/08/11. S16 indicated that Patient #2 had significant medical problems and was in poor health at the time of his admission to LTAC of Slidell. When asked about the condition of Patient #2's buttocks, S16 reviewed the medical record and reported there was no documentation to indicate that her (S16) or her partner (S5) had been immediately notified of the development and progression of the Patient #2's pressure wounds on his buttocks. S16 indicated that she would have expected to have been notified at the time the skin initially broke down on 6/13/11 and would have expected to have been immediately notified when the wound was found to have progressed to a stage IV wound on 6/20/11. After reviewing the medical record, S16 indicated that she did not recall being notified of the pressure wounds on either occasion and did not see where her partner (S5) had been immediately notified. When asked about the use of hyperbaric treatment for Patient #2's wounds, S16 reported she did not feel that Patient #2 would have been an appropriate candidate for hyperbaric treatment according to medicare criteria. When asked about the use of a wound vac for Patient #2's wounds, S16 reported that a wound vac would not be indicated for the type of wound on Patient #2's buttocks.


Patient #6: Medical record review revealed he was a 68 year old man with Alzheimer's dementia related to longstanding Down's Syndrome. His other diagnoses were Aspiration pneumonia and Severe debility. On 1/26/12 a broken blister was found on back of his left upper thigh and an area was found on his right knee by S6LPN. A verbal order was written on 1/26/12 at 0100, "Skin and Wound Care. 1. Left posterior thigh open area clean with NS (normal saline) cover with hydrocolloid dressing, change every 3-5 days and prn (as needed). 2. Right knee Stage I clean with N/S (normal saline) cover with border gauze, change MWF (Monday,Wednesday and Friday) and prn. v.o(verbal order) signed by S6LPN/ S13MD." The order was not authenticated at the time the medical record was reviewed.

An interview was conducted with S6LPN(Licensed Practical Nurse) on 1/26/12 at 1:35 p.m. She stated she had staged the wound on Patient #6 and wrote the verbal order for S13MD. She went on to report she did not call the doctor for the verbal order, if the doctor disagreed, the physician would just change the order in the morning. She reported she did not call the doctor prior to writing the verbal order.

An interview was conducted with S4Wound Care RN on 1/26/12 at 2:45 p.m. She reported S6LPN used to work with her as a wound care nurse until recently. She further reported if a LPN found a skin issue, the LPN can write the verbal order. If she (S4) agreed with the order she would show it to the doctor when she made rounds and the physician would sign the verbal order. She reported she did not know if the LPN called the doctor prior to writing the verbal order on 1/26/12.

An interview was conducted with S1DON on 1/26/12 at 2:50 p.m. She reported there were no standing orders for wound care.

Based on record review, observation and interview the hospital failed to ensure wound care was performed according to CDC (Center of Disease Control) recommendations for Hand Hygiene. This was noted during the observations of 2 of 2 wound care treatments observed (Patient #1 and Patient #3) and failed to ensure the hand sanitizer used in the hospital was recommended by the CDC for use by Health Care Workers. Findings:

Patient #1
Review of the medical record for Patient #1 revealed she was 52 year old female admitted in August 2011 to a hospital in Mississippi with Fournier's gangrene. She had a massive infection in her upper left thigh, which was accompanied by multi-organ failure. In November of 2011 she was transferred to a Long Term Acute Care Hospital (LTAC) on a ventilator and then had to be transferred to another acute care hospital for pneumonia and a new vascular access for dialysis. She was transferred after the hospitalization to the present LTAC on 1/11/12. Her current diagnoses include: Diabetes mellitus Type I, Diabetic nephropathy with chronic renal insufficiency with acute renal failure secondary to sepsis syndrome, Gangrene of the left thigh and groin, Status post extensive debridement, history of diverting colostomy because of a Stage 4 sacral pressure ulcer, history of Dysphagia with PEG tube placement, history of stroke with right sided weakness and history of Encephalopathy. She also had a trach and was on a ventilator.

Patient #1 had 3 wounds that were being treated at the hospital. As of 1/23/12 her sacral pressure wound measured 7 cm (centimeters) X 3 cm X 2.4 cm. The wound was classified a Stage IV with moderate serosangeous drainage and tunneling at 12:00 of 1.2 cm. She was on a wound vac and mist therapy for the sacral wound. She also had a Stage IV occipital pressure wound that measured 1 cm X 1 cm X .1 cm. Her last wound was the site of the abscess on her left inner thigh. The measurements were 10 cm X 4.5 cm X.1cm.

1. Review of the Physician's Orders dated 1/10/12 revealed the skin and wound care order was:
1. Turn q (every) 2 hours side to side.
2. Float heels.
3. Occipital Stage IV - clean with N/S (normal saline). Puracol and cover and change MWF (Monday, Wednesday, and Friday).
4. Sacral Stage IV- clean with N/S. Santyl cover with N/S moist gauze and form dressing daily.
5. L (left) inner thigh- perineum abscess-clean with N/S. Puracol and cover with x 2 border gauze. Change MWF.
6. Mist sacral MWF.
On 1/20/12 a wound vac was ordered for her sacral pressure ulcer.

An observation was made on 1/25/12 at 10 a.m. of S4Wound Care Nurse performing wound care on Patient #1. She started with the sacral wound and removed the wound vac, removed the dirty bandage, changed gloves, performed mist therapy, redressed the wound and changed gloves. She then performed wound care on the patient's left thigh and changed gloves afterwards and started performing wound care on the occipital Stage IV wound. S4Wound Care Nurse did not wash her hands after removing her gloves in between the wounds she performed wound care on.

An interview was conducted with S2Infection Control Nurse on 1/25/12 at 2:30 p.m. She reported S4Wound Care Nurse should had changed her gloves and washed her hands with soap and water between providing wound care to the patient's different wounds.

Patient #3
Review of the medical record for Patient #3 revealed he was a 76 year old male admitted to the the hospital on 01/04/12 for a Atrial fibrillation/flutter and bilateral buttocks Stage II Pressure Ulcers. Review of the Treatment Administration Record revealed an order for Bilateral buttock pressure ulcer-clean with normal saline, Santyl, cover with normal saline gauze and foam dressing daily.

An observation was made of S4Wound Care Nurse performing wound care on Patient #3 on 1/25/12 at 10:50 a.m. S4 performed wound care on his buttocks with gloves on. After she was completed with wound care, with the same gloves on she performed wound care with, she reposition the patient's pillow, pulled his privacy curtain around his bed, and moved his wheelchair. Then she removed her gloves and discarded them and used the hand sanitizer located in the patient's room in a dispenser on the wall to sanitize her hands.

An interview was conducted with S4Wound Care Nurse and she reported she should had removed her gloves prior to touching the pillow, curtain, and wheelchair.

An interview was conducted with S1DON on 1/25/12 at 2:15 p.m. She reported S4Wound Care Nurse should had removed her gloves and washed her hands prior to touching the items in the patient's room.

Review of the CDC's (Center of Disease Control) Guideline for Hand Hygiene in Health-Care Setting revealed in part,"...Decontaminate hands if moving from a contaminated- body site to a clean-body site during patient care. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. Decontaminate hands after removing gloves...Definition of Terms. Decontaminate hands. To reduce bacterial counts on hand by performing antiseptic hand rub or antiseptic handwashing..."

Review of the hospital's policy on Surveillance, Prevention, and Control of Infection; Bloodborne Pathogen Standard; Policy No.: III-D.4.16 revealed in part, "...Hands should also be disinfected before and after gloving, between patients, between separate procedures on any one patient, at the beginning and end of a shift, and any item asepsis is required and there is doubt regarding hand cleanliness..."


2. An interview was conducted with S1DON on 1/27/12 at 10 a.m. She provided the name of the hospital's Hand Sanitizer with the manufacture's information that was used in the hospital and located in the patient's rooms in wall dispensers. She further reported the salesman had stated it was effective against Clostridium Difficile (C-diff). She stated they currently had a patient in the facility that was positive for C-diff. The Hand Sanitizer was manufactured by Company "A". It was listed as an alcohol free antiseptic foam hand sanitizer that kills up to 99.99% of common germs. The active ingredient was listed as Benzalkonium Chloride 0.10 %.

Review of Company "A's" list of the organisms that the Hand Sanitizer was not effective against was as follows: Candida albicans, Enterobacter cloacae, Enterobacteriaclae, Escherichia coli, Hantavirus, Hepatitis A, B, C virus, Herpes Simplex Type I and II, Human Coronavirus, Influenza A, Legionella pneumophilia, Listeria Manocytogenes, MRSE, Proteus mirabilis, Proteus vulgaris, Respiratory syncyial virus, Rhinovirus, Rotavirus, Tuberculosis, VRE and Vibrio Cholera. The information sheet did not list the hand sanitizer as being effective or ineffective against C-diff.

Review of the CDC's Guidelines for Hand Hygiene in Health Care Settings revealed in part, "...Quaternary ammonium compounds are composed of a nitrogen atom linked directly to four alkyl groups...Of this large group of compounds, alkyl benzalkonium chloride are the most widely used as antiseptics....they are more active against gram-positive bacteria than against gram-negative bacilli. Quaternary ammonium compounds have relatively weak activity against mycobacteria and fungi...Insufficient data exist to classify them as safe and effective for use as an antiseptic handwash...because of weak activity against gram negative bacteria benzalkonium chloride is prone to contamination by these organisms. For this reason, in the United States, these compounds have been seldom used for hand antisepsis during the last 15-20 years...Further studies of such products are needed to determine new formulation are effective in health-care setting.." Further review of the Guideline for Hand Hygiene in Health Care Setting revealed,"...Selection of hand-hygiene agents-Alcohol-based hand rubs are the most efficacious agents for reducing the number of bacteria on the hands of personnel. Antiseptic soaps and detergents are the next most effective, and non-antimicrobial soaps are the least effective... During outbreaks of C. difficile-related infections, washing hands with a non-antimicrobial or antimicrobial soap and water after removing gloves is prudent..."

Multiply attempts were made to contact Company "A". The contact phone number and the emergency phone number on their information packet and their website on the hand sanitizer had been disconnected. A phone call was placed to the sales representative by the hospital and the surveyor on separate days and the calls were not returned.

Based on record review and interview, the registered nurse failed to ensure medication was administered as ordered as evidence by a pulse was not checked prior to administration of Metoprolol and Betapace as ordered by the physician for 1 out of 6 sampled patients reviewed. (#3). Findings:

Review of the medical record for Patient #3 revealed he was a 76 year old male admitted to the hospital on 1/04/12 for Atrial fibrillation/flutter and chronic diastolic heart failure.

Review of his physician orders dated 1/05/12 at 0500(5:00 a.m.) revealed an order to Hold Betapace and Metoprolol for HR (heart rate) < (less than) 60.

Review of MAR (Medication Administration Record) for 1/11/12 revealed no pulse documented on the MAR for the 9:00 a.m. Metoprolol or Betapace. A pulse was also not documented for the 21:00 ( 9 p.m.) Betapace dose. Review of the graphic sheet for 1/11/12 revealed the patient had a heart rate of 47 beats per minute (bpm) at 10 a.m., 50 bpm at 2 p.m., 51 bpm at 6p.m., 50 bpm at 10 p.m., and 53 bpm at 2 a.m.

Review of the MAR for 1/17/12 revealed no pulse documented on the MAR for the 9:00 p.m. Betapace dose. Review of the graphic sheet for 1/17/12 revealed the patient had no documented heart rate from 6 p.m. to 2 a.m.

Review of the MAR for 1/23/12 revealed no documented heart rate for the 9:00 a.m. dose of Betapace and Metoprolol. Review of the graphic sheet for 1/23/12 revealed a heart rate of 58 bpm at 6:00 a.m., 54 bpm at 10 a.m., 51 bpm at 2 p.m., 55 bpm at 6 p.m., and 57 bpm at 10 p.m.

An interview was conducted with S1DON on 1/26/12 at 10:30 a.m. She confirmed there was no documentation of the patient's heart rate prior to administration of the medication on 1/11/12 at 9:00 a.m. and 9 p.m., 1/17/12 at 9 p.m., and 1/23/12 at the 9 a.m. dose.