HospitalInspections.org

Based on review of medical records (MR), facility policy and procedures, patient and staff interviews, it was determined staff failed to:

1. Provide tube feedings as ordered by the physician, which affected 2 of 2 MR's reviewed with tube feedings, including Patient Identifier (PI) # 3 and PI # 1.

2. Ensure physician orders were obtained for care of Tracheostomy (trach), which affected 1 of 2 MR's, reviewed with a trach, including PI # 3.

3. Notified physician of foul smelling drainage from the trach, which affected PI # 3.

4. Provide trach care as ordered by the physician, which affected 1 of 2 MR's reviewed with a trach, including PI # 2.

5. Provide dietary supplements (Ensure and vanilla ensure pudding) as ordered, which affected 2 of 2 MR's reviewed with dietary supplements ordered, including PI # 3, PI # 2.

This deficient practice had the potential to negatively affect all patients admitted requiring nutritional support and/or trach care.

Findings include:

Facility Procedure: Tracheostomy Tube Cannula and Stoma Care
Reviewed: 11/18/21

...Special Considerations

....Clean the stoma site every 4 to 8 hours.

...Documentation...Record the date and time of the procedure; type of procedure preformed...

1. PI # 3 was admitted to the facility on 11/17/21 with diagnoses including Acute Septic Shock and Hypoxic Respiratory Failure.

Review of the Physician Order dated 11/18/21 at 12:12 AM revealed the order for Tube Feeding Continuous: Nepro 45 milliliter (ml)/hour (hr) per PEG (Percutaneous Endoscopic Gastrostomy) Flush with 30 cubic centimeters (cc) water.

Review of the Intake and Output sheet dated 11/18/21 to 11/22/21 documentation of Enteral Tube Intake: PEG Tube Abdominal wall as:

11/18/21 12:12 AM to 1:04 PM: 45 ml. There was no documentation the continuous Nepro was administered at 45 ml/hr.

Review of the Physician Order dated 11/18/21 at 1:04 PM revealed Tube Feeding Orders: Tube Feeding Bolus Nepro per G-TUBE, 240 ml, Daily if P.O. (by mouth) is less than 50% at each meal, plus 360 ml at 10:00 PM. 180 ml water flushes with each bolus. Dietary supplements TID (three times a day) meals vanilla ensure pudding with meals.

Further review of the Intake and Output sheet dated 11/18/21 to 11/22/21 documentation of Enteral Tube Intake: PEG Tube:

11/18/21 1:04 PM to 11/19/21 7:00 AM: 0
11/19/21 7:00 AM to 11/19/21 7:00 PM: 0
11/19/21 7:00 PM to 11/20/21 7:00 AM: 0
11/20/21 7:00 AM to 11/21/21 7:00 AM: 0

There was no record the daily meal % was documented for each meal, no documentation Nepro bolus tube feedings were administered at 10:00 PM or TID vanilla ensure puddings were provided as ordered.

Review of the medical record revealed the only Trach Tube care was documented on
Respiratory Procedure Progress note dated 11/19/21 9:44 PM and revealed,
"Single cannula # 6:
Trach Tube Care: Dressing changed, Inner cannula cleansed, Suction, trachea.
Trach Tube Assessment: Routine Assessment
Trach Dressing Description (Desc) Drainage present
Trach Stoma Site Desc: Skin intact
Trach Site Drainage Desc: Foul smelling, secretions, dried...

Pt's trach uncapped per MD (Medical Doctor) order. Trach cleaned with sterile water and peroxide. Pt sx (suctioned) with small amount of thin white secretions removed, faint odor noted. Pt placed back on 28% t/c (trach cap for the night..."

During an observation of care conducted on 11/23/21 at 8:10 AM the surveyor observed a pink padded dressing under trach and labeled with the date of 11/18/21 6:00 AM and staff initials.

The surveyor asked PI # 3, "Have you received a bolus of Nepro tube feeding each night at 10:00? PI # 3 replied, "They came in last night around 11:00 PM last night and gave me one. That's the first time, and that was too late."

Then the surveyor asked PI # 3 and spouse, "How often does the staff assess/ provide trach care?" PI # 3 looked at spouse then replied, "Maybe every other day, I'm not sure."

In an interview conducted on 11/23/21 at 12:05 PM, Employee Identifier (EI) # 2, Chief Nursing Officer (CNO) confirmed the staff failed to follow physician orders for enteral feedings, TID nutritional supplements, or obtain physician orders for trach care.


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2. PI # 1 was admitted to the facility on 6/22/21 with a diagnosis of Left Frontal Infarct.

Review of the Physician Orders dated 6/22/21 at 6:57 PM revealed an order for Nepro 55 ml/hr to be administered via Gastrostomy Tube from 6 pm until 6 am with a 40 ml/hr fluid flush.

Review of the nursing notes and I & O dated 6/22/21 and 6/23/21 revealed no documentation of the Nepro and fluid flush administration via Gastrostomy tube on 6/22/21 from 6 pm to 6/23/21 at 6 am as ordered.

An interview was conducted on 11/23/21 at 12:46 PM with EI # 2, who confirmed there was no documentation Nepro and the fluid flush was administered via Gastrostomy tube on 6/22/21 from 6 pm until 6/23/21 at 6 am per the physician's order.

3. PI # 2 was admitted to the facility on 10/20/21 with a diagnosis of Disuse Myopathy.

Review of the Physician's Order dated 10/20/21 at 9:44 PM revealed an order for Trach Care once every 12 hour shift.

Review of the MR revealed:

No documention of trach care on 10/20/21 and 10/21/21.
Trach care was performed on 10/22/21 at 10:55 AM by the Respiratory Therapist. There was no documentation trach care was performed a second time on 10/22/21.
Trach care was performed on 10/23/21 at 4:54 PM by the Registered Nurse (RN). There was no documentation trach care was performed a second time on 10/23/21.
Trach care was performed on 10/24/21 at 10:26 AM by the RN. There was no documentation trach care was performed a second time on 10/24/21.
Trach care was performed on 10/25/21 at 7:40 PM by the RN. There was no documentation trach care was performed a second time on 10/25/21.
Trach care was performed on 10/26/21 at 6:04 PM by the Licensed Practical Nurse. There was no documentation trach care was performed a second time on 10/26/21.
No documention of trach care on 10/27/21 and 10/28/21.

Review of the Physician's Order dated 10/21/21 at 12:53 AM revealed an order for Ensure three times a day with meals.

Review of the MR revealed:

No documentation Ensure was provided to the patient on 10/21/21 and 10/22/21 for breakfast, lunch, and dinner.
Ensure was provided to the patient on 10/23/21 at 7:07 AM and 6:23 PM. There was no documentation Ensure was provided to the patient at lunch.
Ensure was provided to the patient on 10/24/21 at 1:27 PM. There was no documentation Ensure was provided to the patient at breakfast and dinner.
Ensure was provided to the patient on 10/25/21 at 12:00 PM and 5:00 PM. There was no documentation Ensure was provided to the patient at breakfast.
No documentation Ensure was provided to the patient on 10/26/21 and 10/27/21 for breakfast, lunch, and dinner.
No documentation Ensure was provided to the patient on 10/28/21 for breakfast.

An interview was conducted on 11/23/21 at 2:39 PM with EI # 2 who confirmed there was no documentation trach care and Ensure were provided to the patient on the above dates and times.

Based on observations, review of Centers for Disease Control and Prevention (CDC) guidelines, facility policy and procedures, and interviews, it was determined the staff failed to perform hand hygiene per policy.

This affected Patient Identifier (PI) # 3, and had the potential to negatively affect all patients served by the facility.

Findings include:

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

When to Perform Hand Hygiene:

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

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

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

After glove removal.

CDC "Clean Hands Count for Patients"

How should your healthcare providers clean their hands?

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

Facility Policy: Hand Hygiene
Policy Number: 170
Date: 2/19/21

Purpose: To decrease the risk of transmission of infection by appropriate hand hygiene

Policy: Every employee will use proper hand hygiene and hand washing techniques.

Indications for Handwashing and Hand Antisepsis ...

Wash hand after removing gloves...

1. PI # 3 was admitted to the facility on 11/17/21 with diagnoses including Acute Septic Shock and Hypoxic Respiratory Failure.

In an observation of care conducted on 11/23/21 at 8:10 AM, the surveyor observed Employee Identifier (EI) # 3 Licensed Practical Nurse (LPN) administer medication via feeding tube. EI # 4, Charge Nurse was also present during the observation.

EI # 3 applied gloves and obtained water from the sink, to use as a flush for feeding tube, turned off the faucet with gloved hand. Then, EI # 3 LPN administered medication via feeding tube and flushed with water and removed gloves and reapplied gloves without performing hand hygiene.

EI # 3 continued administer 4 more medications and followed the same process of applying gloves, touching the sink faucet with gloved hands, administering medications, removing gloves and reapplying gloves and failing to perform hand hygiene.

EI # 4 confirmed the deficient practice at the end of the medication administration observation.

In an interview conducted on 11/23/21 at 12:05 PM, EI # 2, Chief Nursing Officer, confirmed the staff failed to follow facility policy for hand hygiene.