HospitalInspections.org

Based on interview and record review, the facility's registered nurse failed to supervise and evaluate the nursing care for 1 of 1 patient (Patient #1) who developed two pressure ulcers that was hospital acquired during a hospitalization in 2014.

Findings included:

Patient #1 was admitted on 2/28/14 for infected hip. The History and Physical and the initial nursing assessment documented the patient had 2 community acquired wounds. One was a surgical incision to the right trochanter (hip) and the other was a pressure ulcer to right heel.

On 3/17/14 Physician #5's progress note indicated Patient #1 had "2 new small areas of purplish discoloration, one to the right lateral heel and one to the right posterior distal lower leg...Impression and Plan...right lateral ankle and right lower leg wound possibly due to DTI (deep tissue injury)...Continue with Xenaderm to all...sites at this time..." Physician #5 wrote an order for dressing the new wounds.

There was no documentation that the nurses addressed the 2 new pressure ulcers and the dressing changes according to the physician's orders.

In a phone interview on 12/8/15 at 1:25 PM, Personnel #2 was informed of the above findings. Personnel #2 confirmed the findings and stated the nurses did not document that Patient #1 had developed 2 new pressure ulcers during her hospitalization.

Based on observation, interview, and record review, the facility failed to implement a policy governing infection control in that on 12/7/15:

A) 1 of 1 Personnel (Personnel #4) did not secure the ties of the gown when entering a patient's room who was on contact isolation, and

B) 1 of 1 open plastic bag that contained disposable washcloths was found behind the sink's faucet ready for patient use. The bag being opened and the location it was stored increased the possibility of cross-contamination.

Finding's included:

During a tour on the 3rd floor to visit Patient #1 on 12/7/15 at 11:40 AM, the following was observed:

A) Patient #1 was on contact isolation. Prior to entering the patient's room all individuals must wear an impervious gown and gloves. Personnel #4 came to the room to deliver a cup of ice to Patient #1. The surveyor observed Personnel #4's gown was not tied.

B) Before leaving Patient #1's room, the surveyor washed her hands and observed a small open bag behind the sink's faucet labeled "Bedside Care-EasiCleanse-disposable washcloths." When the faucet was used, water could potentially trickle inside the open bag and may cross-contaminate the disposable washcloths which were ready for patient use.

At approximately 12:10 PM on 12/7/15, Personnel #1, #2, and #3 were outside Patient #1's room. They were notified of the above findings. They were asked to provide a policy and procedure for donning a gown. Personnel #3 went in the patient's room to verify the open bag of disposable washcloths and she confirmed the findings.