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10802

Based on observation, interview and record review, facility ' s registered nurse failed to supervise the care of patients in the facility, in that patients were not assessed during initial assessment and every 24 hours by a registered nurse, patients were not weighed as ordered by the physician, facility registered nurse did not identify and secure treatment of stage 2 pressure sore on a patient,

Findings'

A: Patients were not assessed during initial assessment and every 24 hours by a registered nurse
Review of patient # 3 CL ' s clinical record (demographic data) revealed he was admitted to the facility 07/12/2011 with admitting diagnosis of post obstructive pneumonia and congestive heart failure, Alzheimer ' s

Review of the patient ' s Initial Nursing Assessment and Admission Data Base dated 07/12/2011 revealed the Initial Nursing Assessment was completed by licensed vocational nurse#13 CL at 17:35 p.m.
Sections on the Admission Data Base dated 07/12/2011, i.e. Braden Scale was incomplete, nutrition screen was blank. The Admission Data Base indicated that the patient had reddened area all over, open exposed tissue to the buttocks and an area on the arm unidentified. Sections which addressed measurement of the wound was blank.

Review of a interdisciplinary plan of care date 07/12/2011 at 2200 documented that complete risk assessment tool ( Braden) was initiated, implemented wound prevention per pressure Ulcer Prevention Protocol, Provide wound prevention and management per orders . The patients Skin assessment on the admission data was incomplete.

Review of the Admission Data base dated 07/12/2011 documented that the patient was on contact isolation for scabies.
The patient ' s plan of care dated 07/12/2011 which addressed High infection risk or infection process was blank.

Cross reference A395


B: Patients were not weighed as ordered by the physician:
Patient #6 CL
Patient #6 CL was admitted to the facility with diagnosis of End Stage Renal Disease on hemodialysis three times weekly.
Review of patient #6 CL's clinical record revealed a physician ' s order dated 07/08/2011 for Patient weight three times weekly before hemodialysis.

Review of the patient ' s hemodialysis flow sheets revealed the patient received hemodialysis treatment three times weekly on the following dates: 07/09/2011, 07/12/2011, 07/14/2011, 07/16/2011,07/19/2011, 07/21/2011, 07/23/2011, 07/26/201107/28/2011 and 0730/2011.
Review of the treatment sheets revealed no documentation that the patient was weighed prior to hemodialysis as ordered by the physician.
Cross reference # A

C: Facility registered nurse did not identify and secure treatment of stage 2 pressure sore on a patient id #1 CL.

Patient #1CL
On 08/01/2011 at 11:17 a.m. during the examination by the primary care (registered nurse #14 CL) the surveyor observed a pressure sore between the patient #1CL sacro coccygeal area. The skin was broken and raw.

During an interview on 08/01/11 at 11:20 a.m. with the patient ' s primary care registered nurse, the surveyor asked the nurse if she was aware that patient #1CL patient had this pressure sore to her sacro coccyx and requested to have it staged.
The primary nurse said she knew the patient had some redness but she was not aware of the pressure sore.

Cross reference A 395


17028


Based on observation, interview, and record review the facility assigned patient care to Licensed Vocational Nurses and failed to ensure there was assigned Registered Nurses to supervise and evaluate the care of the patients.
The facility failed to implement the it ' s Nurse- Staffing Plan # NR110E which " provides for sufficient number of Registered Nurses to carry out responsibilities, and accountability to prescribe, delegate, supervise and direct the nursing care provided in hospital " .
The failed practice had the potential for inadequate assessment and evaluation of patient care needs. Citing patients on three (3) of three (3) wings on the Second floor Medical Surgical Unit.
Refer to 482.23(b) at A392.

Based on record review and interview the facility's Nursing staff failed to supervise the care of patients to ensure they were weighed as ordered by a physician and that initial assessment was completed by a Registered Nurse per the facility's protocol. Citing Patient #s CL14, CL17, and CL21.
Refer to482.23(b)(3) at A395.

Based on observation, record review and interview, facility failed to ensure contracted hemodialysis staff provided hemodialysis service as prescribed by the physician in 1 of 3 sampled patients on dialysis from a sample of 15 in - patients and 6 discharged records. Citing patient #6 CL

Findings:

Patient #6 CL
Patient #6 CL was observed in his room on 08/02/2011 at 7:30 a.m.
On 08/02/2011 at 7:30 a.m. contract hemodialysis nurse #18 CL was observed examining patient # 6 CL and setting up his hemodialysis machine for hemodialysis treatment in the patient ' s hospital room. The nurse primed and set up the machine, mixed bicarbonate solution, checked the patients blood pressure and vascular access. The patient was not weighed.

Review of patient #6 CL ' s clinical record (physician ' s orders for admission) revealed the patient was admitted to the facility on 07/08/2011 with admitting diagnosis of End Stage Renal Disease on hemodialysis three times weekly.
Review of patient #6 CL ' s clinical record revealed a physician ' s order dated 07/08/2011 for Patient weight three times weekly before hemodialysis.

Further review of the patient ' s clinical record (hemodialysis flow sheets) indicated that the patient received hemodialysis treatment from a contracted acute hemodialysis service three times weekly.
Review of the patient ' s hemodialysis flow sheets revealed the patient received hemodialysis treatment three times weekly on the following dates: 07/09/2011, 07/12/2011, 07/14/2011, 07/16/2011,07/19/2011, 07/21/2011, 07/23/2011, 07/26/201107/28/2011 and 0730/2011.
Review of the treatment sheets revealed no documentation that the patient was weighed prior to hemodialysis as ordered by the physician.

On 08/02/2011 at 7:40 a.m. surveyor notified the contracted registered nurse #18 CL that the patient was not weighed prior to hemodialysis treatment. Registered nurse #18 CL did not respond.

On 08/02/2011 at 3:00 p.m. the surveyor reviewed patient #6 CL' s clinical record with facility 's chief clinical care officer and informed her that the patient was not weighed as ordered by the physician. She reviewed the record and confirmed that there was no indication that the patient was weighed as ordered by the physician.

Based on review of patients ' clinical record and interview, the facility failed to operationalize its policy and procedure to stabilize patients who presented to facility's treatment room with emergent condition in 2 of 21 medical records reviewed #s, 8 CL, 9 CL from a sample of 15 in- patients and 6 discharged records at Hospital CL .

Findings:

Review of the facility ' s current policy and procedure # ER 233 directed staff as follows " Patient presenting with emergent and urgent complaints will be transfer to the closest acute care facility by initiating an MOT (memorandum of Transfer). The nursing supervisor will call 911 ambulance for patient presenting with emergent and urgent complaints. Patient with emergent and urgent complaints will be treated as per ACLS guidelines. "
Patient triage as emergent shall receive the highest treatment priority. Examples include cardiac/ respiratory distress. "

Review of the facility ' s policy and procedure on Management of Laceration # ER 344 directed staff as follows: " To utilize appropriate interventions for stabilization, maintenance and treatment of patients with lacerations. Equipment suture Tray, suture, sterile gloves, Local anesthetic, Betadine, Normal saline and Basin. Control active bleeding, Cleanse wound with mild soap and/or antiseptic solution. (Betadine and NS as ordered). Remove obvious small particle debris from wound. Prepare equipment and set up to assist in suturing/ irrigation wound. Explain procedure to patient. apply antibiotic ointment as ordered over wound suturing. Dress wound aseptically per physician ' s specifications.
Administer Po, IM antibiotic per orders. After stabilization of patient arrange for transfer to the nearest hospital capable of providing the needed services as ordered by physician. "

Patient #8 CL
Review of patient #8 CL's clinical record ( nursing Assessment ) revealed the patient presented to the emergency room on 04/06/2011 at 13:30 with presenting chief complaint of cut to right eye.

Review of the patient ' s clinical record revealed an assessment by the physician which documented that the patient was a one year old child who presented with a small laceration over the right orbit of the patient ' s eye. On examination the laceration measured 1.5 cm, non bleeding and shallow.
After the examination the physician ' s documented " Due to lack of proper material to correct. Advised mother to take child to CKLE ER or urgent care for medical attention. "

Review of the patient ' s nursing discharge instruction directed the patient ' s mother as follows: " Prevent child from touching wound, proceed to CLRMC ER. "

Review of the patient ' s emergency room record revealed no indication that the patient was stabilized and transferred as stated in the facility's policy and procedure.

On 08/03/2011 at 10:40 a.m. The surveyor reviewed the patient # 8 CL's clinical record with facility chief clinical officer. She confirmed that there was no indication that the patient was stabilized and transferred as stated in facility ' s policy and procedure.

Patient #9 CL
Review of patient #9 CL's clinical record (nursing assessment) revealed the patient presented to the facility's treatment room on 01/31/2011 at 8:50 with presenting chief complaint of fever and chills, generalized pain and weakness. Assessment by the nurse indicated that the patient's " skin is hot to touch " , flushed and was experiencing sharp pain in legs and head with a pain scale of 9/10.

Further review of the patient ' s clinical record (nursing assessment) revealed the following documented vital signs: 8:50 triage vital signs ;Temperature 104, Pulse 109 beats per minute and respiration 25.

Review of a Medical Screen conducted on patient # 9 CL by the physician in the treatment room, on 01/31/2011 revealed the following documented assessment " Fever, tachycardia and tachypnea ."

Review of the patient ' s clinical record revealed the following documentation by the registered nurse " Pt arrived in lobby proxy 8:30. Pt ac/O fever, chills, generalized pain and weakness. Pt was seen and treated by Dr --------. Pt instructed to go to primary care physician or emergency room at hospital of her choice"

Review of a Discharge Summary instruction signed by the physician revealed the following instructions given to the patient's family " Diagnosis Respiratory distress and fever. Go to _____- Regional Hospital ER for chest x-ray and further evaluation of fever/ cough.

The surveyor reviewed the patient ' s clinical record with facility chief clinical officer. She confirmed that there was no indication that the patient was stabilized and transferred as stated in facility ' s policy and procedure.

Based on observation, record review, and interview the facility failed to ensure restraint order was secured on one of one patient (#1-TE).

Finding Including:

During tour of the hospital with the CCO (#50) on 8/1/11 at 12:10pm, patient #1-TE was observed on a low bed with restraints on both arms. Patient #1 was also observed on rounds on 8/2/11 at 2:00pm with restraints on both arms.

Review of patient #1's medical record on 8/2/11 revealed he was admitted on 7/27/11, diagnoses included Aggressive Behavior, Pneumonia, and history of Schizophrenia/falls. Patient #1 had tube feeding in place and left hand picc line secured with kerlix dressing. Review of nursing assessment dated 7/27/11 revealed patient was very aggressive and combative to both self and staff, made several attempts to get out of bed per nurses' note. An order for restraints was received and signed by the physician on 7/28/11. Further record review revealed daily documentation in the nurses notes for continuous restraint use for patient #1.

Review of physician order sheet on 8/2/11 at 11:00am revealed completed restraint order sheets for patient #1 dated 7/29/11-8/2/11, the restraint orders were not signed by the physician.

Review of facility's restraint policy and procedure # PC 310 titled "Restraint Use" dated 4/1998 and revised 2/18/2008, #2 "while restraints are in use the nursing care givers/designee will audit restraint documentation and compliance daily through the use of the Restraint Log/Restraint Monitoring Form". #3 revealed "A physician must order restraints".
a). Time limited. Restraint orders must be ordered daily. If the restraint is removed for a trial period of time a new order must be obtained to reapply the restraint. (PRN restraints are not used in Triumph Hospitals).

Interview with facility staff #57, who was taking care of patient #1 on 8/2/11 during rounds revealed "he is very combative and tries to fall out of bed all the time and we put him on a low bed and applied restraints to prevent him from hurting himself and staff". Facility staff #57 said that patient #1 had hit several staff members.

Interview with facility staff #50 on 8/2/11 at 11:45am she stated restraints must be signed by the physician daily and it is in our restraint policy".

17028

Based on observation, interview, and record review the facility assigned patient care to Licensed Vocational Nurses and failed to ensure there was assigned Registered Nurses to supervise and evaluate the care of the patients.
The facility failed to implement the it ' s nurse- staffing plan # NR110E which " provides for sufficient number of Registered Nurses to carry out responsibilities, and accountability to prescribe, delegate, supervise and direct the nursing care provided in hospital " .
The failed practice had the potential for inadequate assessment and evaluation of patient care needs. Citing patients on three (3) of three (3) wings on the Second floor Medical/ Surgical Unit.

Findings:

Observation on 8/1/11 at 11:15 am on the second floor Medical Surgical Unit revealed patients were assigned to the care of five (5) Licensed Vocational Nurses (LVN) who did not have Registered Nurse (RN) supervision.
Review of the Staff assignment posted on the unit revealed the LVNs were assigned 6-7 patients each. There was no charge nurse listed for the unit. There was one registered nurse listed as " House Supervisor. "

During an interview on 8/1/11 at 11: 25 am with Staff # CL15 RN House Supervisor, on the second floor medical/ surgical unit, she stated she was the charge nurse on both the second and third floor medical/surgical units and also for the emergency treatment room. She further stated she was also assigned as the house supervisor which meant she oversees activities in all nursing areas.
Staff # CL15, RN House Supervisor stated she was responsible to supervise the LVNs on all the units. When asked by the Surveyor how she was able to address crisis on all the areas she said " she ran from place to place " .

During an interview on 8/1/11 at 1:15 pm with Staff # CL3(Chief Nursing Officer) she stated there was a Registered Nurse assigned to Supervise the LVNs on each twelve hour shift. She further stated all patients were evaluated by a Registered Nurse at least once in a twelve hour shift.

Review of Patient assignment sheets dated 7/30/11- 8/1/11 revealed the following information:
On 7/31/11 patients in rooms 237-243 were assigned to Staff # CL 16, Licensed Vocational Nurse (LVN) on the 7:00 am -7:00 PM shift and were assigned to Staff # CL19, LVN on the 7 PM -7 am shift ( a 24 hour peiod).

On 8/1/11 patients in rooms 235-243 were assigned to Staff CL 16, LVN on the 7:00 am -7:00 PM shift and were assigned to Staff CL19, LVN on the 7pm -7 am shift (24 hours).

There was no documentation that a Registered Nurse was assigned on the unit as charge nurse to supervise the activities of the LVNs. There was documentation that one RN was assigned duties as House Supervisor for the hospital.The House Supervisor was not "immideately available" to supervise all staff in all the various departments.

Review of 24 hour nursing documentation in patients' medical record revealed three patients ' records had no documented evidence of a Registered Nurse ' s (RN) intervention in the patients care. There was signed documentation that the patients were all cared for by Licensed Vocational Nurses (LVN) with no evidence of RN supervision or intervention in their care.

Patient # CL 17 was assigned to the care of LVNs on two consecutive twelve hour shifts on 7/26/11, 7/27/11, 7/31/11 and the 7 am - 7 PM shift on 8/1/11.

Patient # CL 20 was assigned to the care of LVNs on two consecutive twelve hour shifts on 7/20/11, 7/21/11, 7/30/11 and 7/31/11.

Patient # CL14 was assigned to the care of LVNs on two consecutive twelve hour shifts on 7/29/11.

Review of the facility ' s staffing policy NR110E dated October 2010 gave the following information:
" The nurse-staffing plan provides for sufficient number of Registered Nurses to carry out responsibilities, and accountability to prescribe, delegate, supervise and direct the nursing care provided in hospital. This is written into the hospital ' s job descriptions, contracts, nursing policies and procedures and the standards of care.

The team care delivery system provides a staffing matrix in which nursing care is provided for the team by a Registered and Licensed Vocational Nurses and PCAs working together as a team and assisted by the Unit Secretary. "
The RNs assigned to each unit assumes the responsibility and accountability for the direction and supervision of the team, identify patient care needs, prescribe appropriate nursing interventions as indicated and serve as the clinical resource person for LVNs and PCAs on the unit " .

The facility failed to implement its policy by ensuring that Registered Nurses were assigned to directed the care of patients assigned to the LVNs on the unit.

Based on observation, interview and record review, facility' s registered nurse failed to assess and implement plans of care to address patient care needs i.e. hospital acquired pressure sore, Gastrostomy stoma site care, administration of gastrostomy tube feeding, ensuring labs ordered by the physicians were obtained and weighing of patients as ordered by the physician in 7 of 15 in - patients and 6 discharged records reviewed. citing patient #s 1 CL, 2 CL, 3 CL, 4 CL, 14 Cl 17 CL, and 21 CL at hospital CL

Findings:

Patient #1 CL
On 08/01/11 at 11:17 a.m. during tour of unit 300, patient # 1 CL was observed in her room in bed with side rails up X 2. The patient was responsive but confused. The patient had a PEG tube in her abdomen where she received nutritional supplement of fiber source at 60 mls / hour. The insertion site had an accumulation of brown crusty drainage.

Interview with patient ' s primary nurse on 08/01/11 at 11:17 a.m. revealed the patient was dependent in all aspects of activities of daily living, bed bound and did not have a pressure sore, only redness to her groin

Subsequent observation on 08/01/11 at 11:18 am revealed patient # 1 CL was examined by the patient ' s primary nurse and the chief clinical officer.
During the examination the surveyor observed a pressure sore between the patient ' s sacro coccygeal area. The skin was broken and raw.

During an interview on 08/01/11 at 11:20 a.m. with the patient ' s primary care registered nurse, the surveyor asked the nurse if she was aware that the patient had this pressure sore to her sacro coccyxgeal area and requested to have it staged.
The primary nurse said she knew the patient had some redness but she was not aware of the pressure sore.

The facility ' s chief clinical officer who was present said the wound was a stage two pressure sore.

Review on 08/01/11 of the patient ' s clinical record (demographic data) revealed patient # 1 CL was admitted to the facility on 07/28/2011 with diagnosis of Abdominal Wall Abscess with Cellulites.

Review of the patient ' s initial admission physical assessment dated 07/28/2011 section on " Wound sites and Number " revealed patient #1 CL had a PEG tube in place and perineal redness.

Review of the patient ' s most current nurses progress notes dated 08/01/2011 revealed no evidence of any assessment identifying a stage 2 pressure sore.

Review of the patient ' s most current Interdisciplinary Care Plan initiated 07/28/2011 and last revised 07/31/2011 revealed no plan of care to treat a stage 2 pressure sore.
The most current interdisciplinary care plan revised on 07/31/2011 documented " alteration in skin integrity related to incontinence and poor tissue perfusion. Intervention in plan included " Complete risk assessment tool (Braden) on admission and daily. Implement interventions per Pressure Ulcer Prevention Protocol.

On 08/02/201, the pressure sore was staged by the wound care nurse. The measurement provided by the wound care nurse was 4.4 cm X 2 cm x 0.1 cm.

Interview with the patient ' s attending physician on 08/01/11 at 4:05 p.m. in the conference room, the surveyor inquired from the physician if he was aware that the patient had a pressure sore to the sacro coccygeal area. The physician asked the surveyor, what stage was it and said he was not aware of the pressure sore to patient #1 CL.

Patient #3 CL
Review of the facility current policy and procedure on Admission Data Base Guidelines ( policy # 103 E) directed staff as follows " The admission Data Base is to be completed within 24 hours of a patient ' s admission by a RN. The Admission Data Base is to be completed by the RN admitting the patient and utilized until the end of their shift. The RN coming on the next shift should complete the tool if omissions are present and being utilizing the nursing flow sheet for documentation of continued care. "

Review of patient # 3 CL ' s clinical record (demographic data) revealed he was admitted to the facility 07/12/2011 with admitting diagnosis of post obstructive pneumonia and congestive heart failure, Alzheimer ' s

Review of the patient ' s Initial Nursing Assessment and Admission Data Base dated 07/12/2011 revealed the Initial Nursing Assessment was completed by licensed vocational nurse#13 CL at 17:35 p.m.
Sections on the Admission Data Base dated 07/12/2011, i.e. Braden Scale was incomplete, nutrition screen was blank. The Admission Data Base indicated that the patient had reddened area all over, open exposed tissue to the buttocks and an area on the arm unidentified. Sections which addressed measurement of the wound was blank.

Review of a interdisciplinary plan of care date 07/12/2011 at 2200 documented that complete risk assessment tool ( Braden) was initiated, implemented wound prevention per pressure Ulcer Prevention Protocol, Provide wound prevention and management per orders . The patients Skin assessment on the admission data was incomplete.

Review of the Admission Data base dated 07/12/2011 documented that the patient was on contact isolation for scabies.
The patient ' s plan of care dated 07/12/2011 which addressed High infection risk or infection process was blank.


Review of the facility ' s current policy and procedure on Enterable Feeding Policy # PC 108 E directed staff as follows: " After initial placement confirmation, feeding tube placement will be verified by the nursing staff at the beginning of the shift, and prior to each use using the Air Injection, Auscultation method and ?or Aspiration method. Flush the tube before and after medications administration, when feeding is interrupted Check residual every 4 hours and as needed. Tube feeding residual guideline. For bolus feeding check residual before each bolus "

Patient #2 CL
Patient #2 CL was observed in bed in room 309 on 08/02/2011 at 9:50 a.m. The patient had a percutaneous gastrostomy tube in place to her stomach, through which the nurse administered prescribed medications to the patient.
During the procedure licensed vocational nurse #12 CL disconnected the patient ' s percutaneous gastrostomy tube, poured liquid and crushed medication of Folic Acid, Multivitamin, Florastor and pepcid into a syringe, then poured water into the syringe. Licensed Vocational Nurse #12 CL then used the plunger of the syringe to force the content of the syringe into the patient ' s stomach. The nurse did not flush the gastrostomy tube prior to administration of the patient ' s medication. The nurse did not rinse the medication cup after pouring the liquid medication from the cup. Medication remained in the cup so the patient was not administered the prescribed dosage of the medication.

During an interview with licensed vocational nurse #12 on 08/02/2011 at 9:51 a.m. the surveyor informed the nurse that during observation of her administering medication to patient #2 CL via the percutaneous gastrostomy tube she the nurse did not flush the tube prior to administering medication via the tube, that she forced the medication down the syringe into the patient ' s stomach using the plunger of the syringe and that medication prepared for patient #2 CL remained in the cup because the cups were not rinsed thus the patient was not administered the prescribed dosage of medications.

Patient #4 CL
Patient #4 CL was observed in her room on 08/02/2011 at 10:05 a.m. The patient had a percutaneous gastrostomy tube in place to her stomach through which licensed vocational nurse administered medication to the patient.
During the procedure licensed vocational nurse did not check for stomach content residual prior to administering the medication.

During an interview with licensed vocational nurse #13 CL on 08/02/2011 at 10:10 a.m., the surveyor informed the nurse that she did not check for residual stomach content before administering the medication. Licensed vocational nurse said she did not check for residual stomach content because the patient was not getting continuous enteral feed.

Patient #6 CL

Review of patient #6 CL ' s ' clinical record revealed a physician ' s order dated 07/09/2011 for " HBsAG, HbAnti, Hb core and Hep C. "

Review of the patient ' s clinical record revealed no evidence that laboratories studies were done as ordered by the physician.
Further review of the patient ' s clinical record revealed an physician ' s order dated 07/17/2011 15.00 for HbsAg stat Hepatitis B profile Stat.
Review of the patient ' s clinical record revealed a final laboratory report and result was made available on 07/18/2011 at 0300 a.m.

The surveyor reviewed patient # 6 CL ' s clinical record with the interim manager for the intensive care unit. She confirmed that the laboratory results were available for physician ' s order dated 07/09/2011 and that the stat laboratory result was available on the record approximately




17028

Patient # CL 14

Review of admission assessment notes for Patient # CL 14 revealed she was admitted on 6/30/11. Her admission assessment was completed by the LVN assigned to her care. There was no documentation for more than twenty four hours that a Registered Nurse supervised or evaluated the care of the patient.
Review of physician ' Review of physician ' s orders for Patient # CL 14 revealed orders for weekly weights dated 6/30/11, there was no documentation that weights were done on the week of 7/3/11-7/9/11, 7/10/11-7/16/11, and 7/24/11-7/30/11. There was no weight documented for 7/31/11-8/3/11. Physician's orders and dialysis flow sheet documented that the patient started hemodialysis on 7/1/11 three times a week. Review of the dialysis flow sheets dated 7/1/11 - 8/1/11 revealed there was no documentation that the patient was weighed pre or post dialysis treatment.

Patient # CL 21

Review of physician orders dated 7/1/11 for Patient # CL 21 revealed an order for daily weights. The patient was diagnosed with Renal Failure, Severe Malnutrition and Respiratory Failure. For the period 7/1/11- 8/3/11 there was one documented weight.

Patient #CL 17

Review of physician orders for Patient # CL 17 revealed the patients started hemodialysis three times a week on 7/1/11. Review of the Hemodialysis flow sheets for 7/1/11-8/1/11 revealed there was no documentation that the patient was weighed pre or post dialysis treatment. The dialysis flow sheet had an area for weights however the areas were blank.

Based on interview and record review the Pharmacist failed to ensure STAT and NOW physician orders for medications were administered according to policies and procedures in 3 of 21 records reviewed.
(Patient ID#'s 5, 6, and 27)

Findings include:

Record review of a policy titled "Medication Dispensing Time Frames During and After Pharmacy operating hours" dated 12/27/10 stated "STAT: A medication with an immediate onset of action that is needed in a potentially life threatening or emergency shall be dispensed.........within 30 minutes.
NOW, ASAP, and Missing doses will be interpreted as priority orders and / or dispensed to the patient care areas within 60 minutes."

Patient ID# 5
Record review of a physician order dated 3/3/11 at 11:17 a.m. stated "Lovenox 70mg sub-q injection times one dose STAT." The medication administration record revealed the medication was administered
9 hours and 43 minutes later at 9 p.m. (not within 30 minutes per policy)

Another order dated 3/9/11 at 10:45 a.m. for patient ID# 5 stated "Sodium Bicarb one ampoule STAT and Kayexalate 30 grams orally STAT." The medication administration record revealed the medications were administered 2 hours and 15 minutes later at 1 p.m. (not within 30 minutes per policy)

A physician order dated 3/14/11 at 8 p.m. for patient ID# 5 stated "Lasix 20mg intravenous NOW." The medication administration record revealed the medication was administered 3 hours and 15 minutes later at 11:15 p.m. (not within one hour per policy)

Patient ID# 6
Record review of a physician order dated 2/14/11 at 1:15 p.m. stated "Indocin 25 mg one orally now." The medication administration record revealed the medication was administered 2 hours and 30 minutes later at 3:45 p.m. (not within one hour per policy)

Another order dated 2/15/11 at 3:20 p.m. stated "Potassium Chloride 40 meq orally times one NOW." The medication administration record revealed the medication was administered 1 hour and 40 minutes later at 5 p.m. (not within one hour per policy)

A physician order dated 2/24/11 at 8:00 a.m. stated "Lopressor 5mg intravenous push STAT." The medication administration record revealed the medication was administered 1 hour and 10 minutes later at 9:10 a.m. (not within one hour per policy)

Patient ID# 27
Record review of a physician order dated 8/1/11 at 1 p.m. stated "Intravenous Hydrocortisone 100mg STAT." The medication administration record revealed the medication was administered 1 hour later at 2 p.m. (not within 30 minutes per policy).

Another order dated 8/1/11 at 12:55 p.m. stated "Sodium Bicarb two ampoules STAT and Calcium Chloride one ampoule STAT." The medication administration record revealed the medications were administered
1 hour and 15 minutes later at 2 p.m. (not within 30 minutes per policy).

The Pharmacist (ID# 80) confirmed 8/2/11 at 10:30 a.m. that "NOW" orders should be administered within 1 hour and "STAT" orders should be administered within 30 minutes.

Based upon observations, interviews and record reviews the hospital failed to maintain a clean/sanitary environment (TE).

Heavy build-up [1/8 inch] of dust/lint on horizontal surfaces in the following areas. (Endoscopy Suite/Endoscopy Recovery Room/Dialysis Room/PACU (Post Anesthesia Care Unit)

Finding Include:

During tour of hospital the following were observed on 8/1/2011 at 10:05 am:

Endoscopy suite and Endoscopy recovery areas with Chief Clinical Officer (CCO, #50) were observed to have heavy dust / lint build-up (1/8 inch) on the horizontal surfaces of the cardiac monitors, 4 sharp containers, top of 3 electrical plugs and 2 alcohol pads found on the floor of the Endoscopy recovery room with heavy red stains.

PACU (Post Anesthesia Care Unit) with Chief Clinical Officer (#50) at 10:35 am. Surveyor observed heavy dust / lint build-up (1/8 inch) on top horizontal surface of 3 electrical plugs and top 3 sharp containers.

Dialysis room (storage for dialysis machines) with Chief Clinical Officer (#50) at 11:15 am. Surveyor observed heavy black stains on the carpet.

Review of Triumph Hospital Policy: Infection Control - Housekeeping for the entire hospital: "Infection Control Rounds" dated 2010 and 6/2011 revealed round was conducted in Intensive Care Unit (ICU) area and no mention of both the Endoscopy Suite/Endoscopy recovery and the PACU. Review of facility's house keeping record titled "Terminal Clean After Discharge" revealed "dust mop entire floor surface, check needle container, disinfect all electrical equipment, spot clean visible dirt on walls and other surfaces".

The Infection Control Staff (81) acknowledged on 8/2/11 at 3:20 p.m."we round some areas quarterly, mini rounds when I am on the floor and in operating/endoscopy rooms and recovery rooms. Staff # 81 stated she had not made "rounds in Endo/OR areas in last couple of months".

The Infection Control nurse (ID# 81) stated on 8/3/11 at 1:30 p.m. the hospital does not conduct surveillance rounds of the environment.

The CCO (#50) on 8/1/11 at 11:50 am during initial rounds acknowledged the hospital needs to pay more attention on house keeping and make frequent house keeping rounds.

FINDINGS ARE FOR THE 1700 JAMES BOWIE DRIVE, BAYTOWN THIRD FLOOR SITE:

Based on observations and interviews, the facility failed to maintain the emergency crash cart and ice dispenser machines to ensure a level of safety and quality. Findings include:

A tour of the nursing station on August 2, 2011 at 09:30 revealed the following:

During a tour of the nursing unit on 8/2/2011 at 09:30, the facility's emergency crash cart was inspected. The cart had a bracketed shelf, that when lifted and braced, could be used to hold supplies or equipment being used in an emergency. The lower portion of the shelf had a thick layer of dust and pieces of debris.

The crash cart's suction machine did not work when turned on by hospital staff member #62. The suction machine's plastic jar (to hold suctioned contents) was covered with a plastic lid that was cracked. The crack had been repaired with clear bandage tape. The crack and the repair work with the tape did not allow a vacuum to be developed in the jar and thereby create a suction.

The ice machine tray below the ice dispenser was dirty appearing and when a white cloth was used to wipe the tray, the cloth was blackened from wiping the tray.

Hospital staff (#63, and #64) present duirng the tour confirmed above findings.

Based on observation, interview and record review, the facility failed to ensure facility ' s nursing staff implemented its policy and procedure on hand hygiene, Failed to ensure contaminated equipment utilized for MRSA patient on contact isolation were not used for other patients; Failed to prevent the spread of infection by storing soiled linen in closed containers; ensuring adequate space to separate clean and dirty areas in the surgical suite; and failed to provide separate handwashing facilities from that used to clean dirty instruments. Citing Two(2) of 15 sampled in - patients, and 6 discharged patients from a sample of 21 patients Citing #s #s 6 CL, 19 CL, one of two operating rooms (OR A) and two(2) patient rooms #s 206 and 224.

Findings:

Review of the facility ' s current policy and procedure on Hand Hygiene, Indication for Hand washing and Hand Antisepsis # IC.108 E, directed staff as follows: " Hands should be sanitized using the hospital approved waterless hand antiseptic agent in the following situations: Upon entering the work area, upon leaving the work area, before invasive procedures, before and after contact with patients intravenous devices, before contact with a particular susceptible patient, between contacts with different patients ; between contacts with different care sites on the same patient. For example moving from a contaminated body site to a clean body site during patient care, after contact with a source, such as an inanimate objects (including medical equipment) in the immediate vicinity of the patient, likely to be contaminated with pathogenic organisms, after removing gloves. "

Review of the contracted hemodialysis facility ' s policy and procedure on Cleaning The Treatment Work Area and Machine, which was adopted by the hospital, directed staff as follows: " The hemodialysis machine and work area will be thoroughly cleaned after each patient treatment to prevent cross contamination. Supplies Gloves Cleaning solution of 10% solution of bleach and water ( 200 ml bleach to 1 gallon water.) "

Patient #19 CL

Observation on 08/02/11 a 8:40 a.m. revealed licensed vocational nurse #50 CL was observed administering medication via intravenous, subcutaneous and oral route to patient #19 CL in her hospital room.
During the procedure the nurse donned her gloves then administered subcutaneous Lovenox in the patient ' s abdomen.
Observation at that time revealed a dressing in place to the patient ' s abdomen.
After administering the medication in the patient ' s abdomen, licensed vocational nurse #50 CL then accessed the patient ' s Porta catheter located on the right side of the patient ' s neck. She then administered antibiotic Dobiomycin via the catheter to the patient. Licensed vocational nurse #50 then changed her gloves after administering the intravenous medication but did not cleanse her hands.
She then prepared and administered oral medication to patient #19 CL. Licensed vocational nurse #50 CL then removed her contaminated gloves and left the patient ' s room. The nurse did not wash or cleanse her hands after she had administered medication to the patient.

She then entered the room across the hallway. The nurse did not wash or cleanse her hands,

During an interview with licensed vocational nurse #50 CL on 08/02/11 at 9:00 a.m., the surveyor informed her that she did not cleanse or wash her hands when moving from the dirty area of the patient ' s abdomen to the patient ' s Porta catheter. Licensed vocational nurse #50 CL stated " I am sorry it totally slipped my mind. "

Review on 08/02/2011 of the patient #19' s clinical record (physician ' s progress notes) dated 08/01/2011 revealed the following documentation " infected surgical wound "

Review of the patient ' s clinical record revealed a consultation report dated 07/29/2011 which stated " VRE colonization, UTI. "

Patient # 6 CL
Observation on 08/02/2011 at 7:20 a.m. revealed a sign posted on the patient ' s door indicating that the patient was on contact isolation.

On 08/0 2/2011 at 7:30 a.m. contract hemodialysis nurse #18 CL was observed examining patient # 6 CL and setting up his hemodialysis machine for hemodialysis treatment in the patient ' s hospital room. The nurse primed and set up the machine, mixed bicarbonate solution, checked the patients blood pressure and vascular access.

After the procedure the hemodialysis machine malfunctioned. Contract registered nurse #18 CL removed the contaminated machine from the patient's room with his bare hand, The machine was not cleaned or disinfected. He then walked to the nurses station and retrieved a document with his contaminated hand. The nurse did not wash or cleanse his hands before or after leaving the patient ' s room who was on contact isolation

Contract Registered nurse # 18 CL entered the elevator with the contaminated hemodialysis machine , then proceeded to the storage area where clean and disinfected hemodialysis machines were stored. Registered nurse #18 Cl placed the contaminated machines beside hemodialysis machine #s 11 , 18 20, 28, 24, and 29 .

The surveyor asked contract registered nurse #18 CL if the hemodialysis machines stored in the room were cleaned and disinfected. He answered yes to the question.

During an interview with registered nurse #18 CL in the hemodialysis storage room on 08/02/2011 at 7:50 a.m. , the surveyor informed him the nurse that he did not cleanse / wash his hands after examining patient #6 Cl and that he did not clean the contaminated hemodialysis machine removed from the patient's room who was on contact isolation.
Registered contract registered nurse #18 stated that the machine should have been cleaned with bleach solution.

Review on 08/02/2011 of the patient ' s clinical record (infectious disease report) dated 08/02/2011 revealed the following documentation: " RT foot wound infection MRSA. "

Patient #6
On 08/0 2/2011 at 7:30 a.m. contract hemodialysis nurse #18 CL was observed setting up hemodialysis machine for hemodialysis treatment in patient #6 CL hospital room. The nurse primed and set up the machine, and mixed bicarbonate concentrate for use during hemodialysis treatment.

During the procedure contract hemodialysis registered nurse #18 CL poured the content of bicarbonate powder from a single use container then added water, in a single use jug. The cap for the jug was missing. The nurse used a glove to cover the jug.

During the observation Contract registered nurse #18 CL had several items stored on the hemodialysis machine which was in the patient ' s room. These items included blood lines, catheters, 2 X 2 swabs, Betadine solution and three extra dialyzers.

During an interview with facility ' s contracted registered nurse #18 C l in the patient ' s room on 08/02/2011 at 740 a.m., he said the equipment stored on the contaminated hemodialysis machine in the room of the patient who was on contact isolation for MRSA positive was in preparation to be used on the next patient scheduled to have hemodialysis treatment.

Review of the manufacturer ' s direction for use, Fresenius 2008H directed users as follows: " The containers used for dialysate concentrate should be disinfected once weekly. Dilute bleach may be used for this purpose. This is especially important when bicarbonate concentrates are used since bacteria can grow more rapidly in these solutions.




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Observation on 8/1/11 at 11:45 am in room 224 on the East wing revealed a large splatter of dried urine on the floor with a patient ' s wash cloth on the floor covering a section of the urine splatter.

Observation on 8/1/11 at 1:00 PM in room 206 on the North Wing revealed a sign indicating the patient(#CL 14) in the room was on contact isolation. The patient had just completed her in room hemodialysis treatment. There was soiled bed linen and patient gowns placed on the floor in the patient ' s room.

Review of the facility ' s policy/procedure # IC 200 revised January 2011 documented that the policy is to provide guidelines to reduce the risk of infection transmission. Section 3 documented that " Soiled linen in patient rooms and other areas is stored in a closed container until transported to a soiled utility room.
During an interview on 8/1/11 at 2:30 PM with Staff CL# 2 she stated staff should not have linen stored on the floor it was against the facility ' s policy.

Observation on 8/2/11 at 10:30 am at the facility revealed two operating rooms (OR A&B) on the ground floor. Observation at that time in OR A, revealed the room was set up for procedures. There was a steam sterilizer on a counter top approximately one and a half foot from a sink in the room. There was a standing cabinet next to the sterilizer with wrapped sterile instruments. There was no other sink in the room or immediately outside the room to facilitate hand washing.

During an interview in OR (A) on 8/2/11 at 11:35 am with Staff # CL 51,Surgical Technologist (Tech), she stated the room was used for surgical procedures.
The Surveyor asked where instruments were cleaned, sterilized and stored. Staff # CL 51 stated,when a procedure was completed in the room, soiled instruments were washed in the sink. She stated the same sink was also used for hand washing. According to Staff # CL 51 after the instruments were washed she disinfect them in OR (B) and then take them to OR(A) to be sterilized in the Steam Sterilizer located in that OR (A).

The facility failed to provide adequate space to effectively separate clean instruments and areas from dirty areas. They failed to provide a separate hand washing facilities from that used to clean dirty instruments.

Review of the facility ' s policy/procedure presented during the inspection titled "Infection Control in Special Procedure" # IC 101 documented its purpose as follows:
" The personnel of the Special Procedure will follow all CC and JOSHUA infection control guidelines " .
The policy guidelines did not address infection control measures in the procedure rooms.
The policy did not address cleaning of soiled surgical instruments or separation of clean and dirty areas.

During an interview on 8/2/11 at 3:00 PM with Staff CL# 3, Chief Nursing Officer she stated the policies did not address sterilization and would be revised.