HospitalInspections.org

Based on policy review, record reviews, document review, observations, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The deficient practices identified below had the potential to affect the physical safety and emotional well-being for all 33 inpatients at this facility.

1. The hospital failed to provide care in a safe setting by not following standard precautions or following facility infection control policies related to catheter system care (see findings in tag A0144).

2. The hospital failed to ensure that patients were only placed in restraints according to provider orders and facility policy (see findings in tag A0168).

3. The hospital failed to ensure patients placed in restraints were monitored for safety (see findings in tag A0175).

Based on policy review, record reviews, document review, observations, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Nursing Services. The deficient practices identified below had the potential to affect the physical safety and emotional well-being for all 33 inpatients at this facility.

1. The hospital failed to ensure patients were bathed daily, per facility policy. (see findings in tag A0395)

2. The hospital failed to ensure patients were turned every 2 hours, per facility policy. (see findings in tag A0395)

3. The hospital failed to ensure patients received wound care as ordered and per facility policy. (see findings in tag A0395)

4. The hospital failed to ensure patients received medications as ordered and per facility policy. (see findings in tag A0405)

Based on observation, document review, medical record review, and staff interview it was determined that the facility failed to provide care in a safe setting for 33 out of 33 patients. Findings include.

Facility policy titled Hand Hygiene states " ...Effective Hand Hygiene is considered the basis for an effective Infection Control Program .... Before and after every patient contact... Between patient care activities within the same episode of care ... Before donning either sterile or non-sterile gloves .... Between glove changes and after removing gloves ... Before any patient procedure or medication administration ... Before going into a patient room and before leaving a patient room ..."

Facility policy titled Urinary Catheter (UC) Management (CAUTI [catheter-associated urinary tract infection] Reduction Program) states that the purpose of the policy is to "provide guidelines for Catheter-Associated Urinary Tract Infections (CAUTI) reduction". The policy goes on to outline proper maintenance of the catheter system which includes "Care must be taken to keep the outlet valve from becoming contaminated ... Avoid letting the drainage bag touch the floor."

During observations conducted on 12/16/22 from 10:08 am and 11:50am the following was observed:
-A catheter bag was seen hanging from the patient's bed and resting on the floor.
This was confirmed with Employee 4, Director of Quality on 12/16/22 at 10:33am.

-During medication administration at 10:44am, Employee 7, RN changed gloves without performing hand hygiene.
This was confirmed with Employee #7 at 10:50am on 12/16/22.

-At 11:20 am Employee 9, Nursing Assistant was observed entering a patient room that had contact precautions. Signs were posted at the door. The employee did not perform hand hygiene, don a gown or gloves prior to entering the patient's room. The employee touched a piece of equipment and then left the room.
This was confirmed with Employee 4, Director of Quality on 12/16/22 at 11:20am.

-At 11:30 am Employee 9, Nursing Assistant was observed entering a patient room without performing hand hygiene.
This was confirmed with Employee 1, CEO on 12/16/22 at 11:33am.

Failure to follow infection prevention measures may cause an unsafe setting for patient care and putting patients at risk for infections.

Based on observation, document review, medical record review, and staff interview it was determined that the facility failed to obtain orders for restraint use for 1 out of 3 patients sampled who had restraints (Patient 3). Findings include:

Facility policy titled Restraints and Seclusion states " ...A written order, based on an examination of the patient by the MD/DO or LIP is entered into the patient's medical record on a daily basis when restraint use is clinically appropriate ...Orders for restraints must be renewed on a daily basis ..."

Medical Record review for patient #3 revealed no evidence of a restraint order on 12/6/22.
A. "Flowsheet" documented patient in restraints from 12/6/22 8:00 AM to 11:59 PM

The finding that there was no evidence of a restraint order on 12/6/22 was confirmed with Employee 2, CNO on 12/20/22 at 2:45 PM. Failure to obtain physician orders for restraints perpetuates an unsafe environment for patient care.

Based on observation, document review, medical record review, and staff interview it was determined that the facility failed to monitor patients during restraint use for 3 out of 3 patients sampled who had restraints (Patients 1, 3, and 6). Findings include:

Facility policy titled Restraints and Seclusion states " ...Interdisciplinary Team Member documentation must: ... State observations/interventions/findings from periodic observations, to include safety, comfort, mobility, skin integrity, food/hydration and toileting ...observations every two hours for medical restraint and every 15 minutes for behavioral restraints ..."

A. Medical Record review for patient #1 showed:
Orders placed for non-violent restraints as follows:
11/27/22 at 7:19 AM discontinued on 11/27/22 at 10:12 AM
11/27/22 at 10:12 AM discontinued on 11/28/22 at 10:04 AM
11/28/22 at 10:04 AM discontinued on 11/29/22 at 11:21 PM
No evidence of restraint observations during the following dates and times:
11/27/22 from 6:45 am - 11:34 am (4 hours and 49 min)
11/27/22 from 2:00 pm - 8:00 pm (6 hours)
11/28/22 from 12:00 am - 08:00 am (8 hours)
11/29/22 from 15:55 - 23:21 (5 hours and 26 min)
This finding was confirmed with Employee 6, Nurse Manager on 12/20/22 between 2:15 pm and 3:01 pm.

B. Medical Record review for patient #3 showed:
Orders placed for non-violent restraints as follows:
12/5/22 at 10:28 am discontinued on 12/7/22 at 12:07 am
12/7/22 at 12:08 am discontinued on 12/8/22 at 5:40 pm
12/8/22 at 5:40 pm discontinued on 12/10/22 at 12:47 pm
12/10/22 at 12:47 pm discontinued on 12/10/22 at 4:14 pm
No evidence of restraint observations during the following dates and times:
12/6/22 from 4:00 pm - 8:00 pm (4 hours)
12/7/22 from 2:00 am - 8:00 am (6 hours)
12/8/22 from 2:00 am - 7:45 am (5 hours and 45 min)
12/8/22 from 7:45 am - 8:00 pm (12 hours and 15 min)
12/9/22 from 6:00 pm - 12/10/22 at 2:00 pm (20 hours)
This finding was confirmed with Employee 2, CNO on 12/20/22 at 2:45 pm.

C. Medical Record review for patient #6 showed:
Orders placed for non-violent restraints as follows:
8/12/22 at 4:43 am discontinued on 8/13/22 at 4:00 pm
No evidence of restraint observations during the following dates and times:
8/13/22 from 1:31 am - 1:36 pm (12 hours and 5 min)
This finding was confirmed by Employee 2, CNO on 12/19/22 at 2:40 pm.


Failure to monitor patients in restraints may result in patient injury or death and delay in the discontinuation of the restraint at the earliest possible time.

Based on observation, document review, medical record review, and staff interview, it was determined that the facility nursing failed to supervise and evaluate the nursing care for 7 out of 7 patients sampled (Patients 1, 2, 3, 4, 5, 6, and 7). Findings include:

I. Bathing
Facility document titled General Orientation Select Specialty Hospital Regency Hospital - Nursing Assistants: a Key to Our Success identifies "roles and responsibilities" to include "hygiene routines" which indicates patient bathing is to be done with a minimum frequency of daily.

A. Medical Record review for patient #3 showed:
No evidence of having been bathed the following dates:
10/24/22
10/28/22
This finding was confirmed by Employee 2, CNO on 12/20/22 at 2:15 pm.

B. Medical Record review for patient #4 showed:
No evidence of having been bathed the following dates:
9/26/22
9/28/22
9/29/22
10/1/22
10/2/22
10/3/22
10/4/22
10/5/22
10/7/22
10/8/22
10/19/22
10/21/22
10/23/22
10/24/22
This finding was confirmed with Employee 6, Nurse Manager on 12/20/22 at 10:31 am.

C. Medical Record review for patient #6 showed:
No evidence of having been bathed the following dates:
8/16/22
8/17/22
This finding was confirmed by Employee 2, CNO on 12/19/22 at 2:00pm.

D. Medical Record review for patient #7 showed:
No evidence of having been bathed the following dates:
10/27/22
10/28/22
10/29/22
10/30/22
10/31/22
11/6/22
11/9/22
11/10/22
This finding was confirmed with Employee 6, Nurse Manager on 12/20/22 at 11:46 am.

Failure to bath patients daily, as per policy, prevents the assessment and evaluation of the patient's response to interventions and may cause complications with skin integrity and infection.

II. Turns
Facility policy titled Pressure Injury Prevention states " ...Patients that are bed bound or with limited activity should be repositioned at least every two hours ..."

A. Medical Record review for patient #1 showed
No evidence of turning the following dates and times:
12/20/22 at 1:38 PM - 12/20/22 at 7:00 PM (5 hours and 22 minutes)
12/21/22 at 6:00 AM - 12/21/22 at 9:00 AM (3 hours)

This finding was confirmed with Employee 2, CNO on 12/21/22 at 11:45 am.

B. Medical Record review for patient #4 showed:
No evidence of turning the following dates and times:
9/24/22 at 2:00 pm - 9/24/22 at 4:54pm (2 hours and 54 minutes)
9/24/22 at 5:00 pm - 9/24/22 at 9:00pm (4 hours)
9/25/22 at 5:00 pm - 9/26/22 at 7:00am (26 hours)
9/26/22 at 1:00 pm - 9/26/22 at 5:00pm (4 hours)
9/26/22 at 5:00pm - 9/26/22 at 8:37 pm (3 hours and 37 minutes)
9/27/22 at 9:00 am - 9/27/22 at 5:00pm (8 hours)
9/27/22 at 5:00 pm - 9/27/22 at 9:00pm (4 hours)

This finding was confirmed with Employee 6, Nurse Manager on 12/19/22 at 3:06 pm.

C. Medical Record review for patient #5 showed
No evidence of turning the following dates and times:
7/5/21 at 5:00 pm - 8:00pm (3 hours)
7/6/21 at 4:10 pm - 8:00 pm (3 hours and 50 min)
This finding was confirmed with Employee 2, CNO on 12/20/22 at 11:10 am.

D. Medical Record review for patient #6 showed
No evidence of turning the following dates and times:
7/30/22 at 8:10 pm - 7/31/22 at 4:24 am (8 hours and 14 min)
8/5/22 at 9:00 am - 8/6/22 at 4:29 am (19hours and 29 min)
8/13/22 at 10:00 pm - 8/14/22 at 8:00 am (10 hours)
This finding was confirmed with Employee 2, CNO on 12/19/22 at 3:45 pm.

E. Medical Record review for patient #7 showed:
No evidence of turning the following dates and times:
9/5/22 at 6:51 PM - 9/6/22 at 8:00 AM (13 hours and 9 minutes)
9/7/22 at 11:00 PM - 9/8/22 at 5:00 AM (6 hours)
9/8//22 at 5:00 AM - 9/8/22 at 8:00 AM (3 hours)
9/8/22 at 10:00 pm - 9/9/22 at 8:00 AM (10 hours)
9/10/22 at 12:00 am - 9/10/22 at 7:20 am (7 hours and 20 min)

This finding was confirmed with Employee 6, Nurse Manager on 12/20/22 at 12:01 pm.

Failure to turn patients every 2 hours prevents the assessment and evaluation of the patient's response to interventions and may lead to the risk of developing pressure injuries and worsening skin integrity.

III. Wound Care
Facility policy titled Wound Documentation states " ...Dressing changes and wound site care are documented in the MR [medical record] or EMR [electronic medical record ... "

Facility document titled Unit Based Competencies: Registered Nurse includes the following tasks: " ...Changes dressings as ordered & documents ...Implements pressure ulcer prevention positions ...dressings/interventions per protocols ..."

A. Medical record review for Patient #2 showed:
Wound care orders placed on 11/17/22 for a wound related to a below the knee amputation to be cleaned with normal saline, apply skin prep [barrier film] and allow to dry, apply medical grade honey (nickel thickness), and apply adhesive foam every Monday, Wednesday, and Friday.

No evidence of wound care as ordered on the following dates:
11/30/22
This finding was confirmed with Employee 2, CNO on 12/19/22 at 11:00 am.

B. Medical Record review for patient #4 showed:
Wound care orders placed on 9/23/22 for wounds on the right toe, left anterior foot, left plantar foot, and pressure injury left foot to be cleaned with normal saline and to cover with ABD dressing and secure with roll gauze every Tuesday and Friday.

No evidence of wound care as ordered on the following dates:
10/4/22
10/11/22
This finding was confirmed with Employee 6, Nurse Manager on 12/19/22 between 1:39 pm and 1:52 pm.

C. Medical Record review for patient #7 showed:
Wound care orders from 8/12/22 to 8/19/22 for a sacral pressure injury to be cleaned with normal saline, apply skin prep [barrier film] and allow to dry, apply medical grade honey (nickel thickness), and cover with adhesive foam daily.

No evidence of wound care done as ordered on the following dates:
8/14/22
8/16/22
This finding was confirmed with Employee 6, Nurse Manager on 12/20/22 at 11:19am.

Failure to provide wound care as ordered prevents the assessment and evaluation of the patient's response to interventions and may lead to the risk of worsening skin integrity, the development of infections, and delay in discharge.

Based on observation, document review, and staff interview it was determined that medications were not given per practitioner's orders and facility policy for 2 out of 8 patients sampled (Patients 1 and 8). Findings include:

I. Facility policy titled Gastric/Duodenal Tube Guidelines: PEG [a type of feeding tube], Gastrostomy Tube, Small-bore Nasal Tube, Nasogastric Tube, Orogastric (OG) states " ...Flush tube with 20ml tap water before and after administration of medication via tube ..."

Facility policy Drug Administration - General states " ...Doses shall not be charted before they are administered ..."

During observations conducted on 12/16/22 from 10:08 am and 11:50am the following was observed:
-RN gave medications to patient #8 at 10:21 via PEG tube. Tube was not flushed prior to administration of medications.
-Medications were not documented after administration.

These finding was confirmed with Employee 7, RN at 12/16/22 at 10:50am. Employee 7 stated that medications were scanned prior to preparation and documented at that time.

II. Facility policy titled Diabetes, Glycemic, and Insulin Management states " ...The blood glucose [also known as blood sugar] reference range is 70-120mg/cl ...Insulin is a HIGH ALERT medication ...SubQ [subcutaneous] and IV push insulin doses will be independently verified. The witness will verify the dose based on documented blood glucose level ...Short/Rapid acting insulin (Regular, Lispro, aspart, glulisine, etc.) ... Fast and Rapid acting insulin should be administered within 1 hour of obtaining blood glucose result. If insulin is not given within one hour, repeat finger stick blood glucose ... Document finger stick blood glucose results, amount of insulin administered, and injection site ..."

Facility policy titled Medication Administration states " ...Obtain B/P [blood pressure] prior to administering anti-hypertensives ...Blood glucose results must be documented on the MAR ...Any administration parameters will be noted (BP, Blood sugar, heart rate, etc.) per policy or physician's order ..."

Medical record review for Patient #1 showed:

A. Insulin
The following medication order placed 12/5/22:
-Insulin regular injection 0 - 16 units, subcutaneous, every 6 hours until discontinued according to the blood sugar moderate dose parameters:
-Blood sugar < 70mg/dl: Initiate hypoglycemia treatment
-70 - 150: No Insulin
-150 - 200: 4 units
-201 - 250: 8 units
-251 - 300: 10 units
-301 - 350: 12 units
-351 - 400: 16 units
->400: 16 units and call medical provider

Blood sugar readings on 12/10/22 as follows:
-4:51 am: 366
-12:33 pm: 213
-5:15 pm: 159

Regular insulin administration on 12/10/22 as follows:
On 12/10/22 regular insulin was administered as follows:
-6:19 am: 16 units (1 hour and 28 min after blood sugar reading)
-12:40 pm: 10 units (based on blood sugar of 213, ordered dose would be 8 units)
-6:47 pm: 4 units (1 hour and 32 minutes after blood sugar reading)

Blood sugar readings on 12/20-22 as follows:
-6:07 am: 261
-8:56 am: 245
-12:25 pm: 214
-10:09 pm: 184

Regular insulin administration on 12/20/22 as follows:
-6:09 am: 12 units (based on blood sugar of 267, ordered dose would be 10 units)
-6:06 pm: 8 units (no corresponding blood sugar reading)
-11:36 pm: 4 units (1 hour and 25 min after blood sugar reading)

There was no evidence that the above medication administrations were done per practitioner orders or facility policy.

These findings were confirmed with Employee 2, CNO on 12/21/22 between 11:08 am and 11:20 am.

B. Metoprolol tartrate (an anti-hypertensive medication)
The following medication order placed 11/23/22:
-Metoprolol tartrate tablet, 75mg, by mouth, 2 times daily, until discontinued. Hold if:
-HR [heart rate] less than: 60bpm
-SBP [systolic blood pressure] less than: 110mmHg

Blood pressure readings as follows:
12/15/22:
-10:03 am: 112/65

On 12/15/22 metoprolol tartrate was administered as follows:
-9:39 am (blood pressure reading taken 24 minutes after medication administration)

There was no evidence that the above medication administration was done per practitioner orders or facility policy.

These findings were confirmed with Employee 2, CNO on 12/21/22 at 10:38 am.

Failure to administer medications as ordered and per policy puts patients at risk of drug-related adverse outcomes such as poor control of medical conditions and death.