HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that the registered nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by:
1)The RN failed to ensure patient wound descriptions were completed daily and included size, depth, color, drainage, odor, changes and other characteristics noted for 2 (#1, #2) of 2 patient's medical records reviewed for wound description documentation and photographs;
2) The RN failed to ensure nutritional screenings were completed within 72 hours of admission as per hospital policy for 1 (#1) of 5 (#1, 2,3,4,5) reviewed for nutritional screenings.

Findings

1) The RN failed to ensure patient wound descriptions were completed daily and included size, depth, color, drainage, odor, changes and other characteristics noted for 2 (#1, #2) of 2 patient's medical records reviewed for wound description documentation.

A review of the hospital policy titled: Nursing Wound Care revealed in part:
There are pictures taken of the wounds initially and weekly, unless indicated to show progress.
The wound description will include size, depth, color, drainage, odor (if applicable), treatment performed, tolerance to treatment, changes and any other characteristics noted.
The wound is assessed daily by the registered nurse or physical therapist with documentation.

A review of Patient #1's medical record revealed orders for wound care dated 06/01/2021 7:10 p.m. cleanse wound to sacrum with wound cleanser, apply foam dressing border gauze.
Right heel blister apply foam dressing border gauze. Change dressings to wounds daily. VORB S5NP/S4RN.
06/05/2021 10:30 a.m. Change wound care to cleanse sacral wound with wound cleanser, dry with gauze, apply Duoderm dressing. Change every 3 days and PRN due to soilage. TORB S5NP/ S4RN.
Initial skin/ wound assessment completed 06/01/2021.
Further review failed to reveal a complete daily wound assessment on 06/02/2021- 06/-9/2021 or any wound photographs.

In an interview on 06/10/2021 at 9:25 a.m. S1RNAdm verified the lack of documentation and photographs.

A review of Patient #2's medical record revealed orders dated 01/30/21 11:30 a.m. OK to pull picc line, dressing to right elbow, clean with wound cleanser daily, cover with 4x4 gauze and kerlex secure with tape. TO S6MD/ S7RN.

Review of Patient #2's MAR revealed documented daily dressing changes.
Further review failed to reveal wound care description from 02/04/2021 through 02/12/2021 or any photographs.

In an interview on 06/10/2021 at 11:00 a.m. S1RNAdm verified the lack of wound description from 02/04/2021 through 02/12/2021 and wound photographs.

2) The RN failed to ensure nutritional screenings were completed within 72 hours of admission as per hospital policy for 1 (#1) of 5 (#1, 2,3,4,5) reviewed for nutritional screenings.

A review of the hospital policy titled Food and Nutrition: Screen for Nutritional Status:
All patients are screened for nutritional status and identified for potential nutritional risk within the first 72 hours of admission.

A review of Patient #1's medical record failed to reveal a completed Screen for Nutritional Status.

In an interview on 06/08/2021 at 2:55 p.m. S1RNAdm reviewed Patient #1's medical record and verified it failed to contain a Screen for Nutritional Status. She also stated Dietary assessments are required within 72 hrs.

Based on record review and interview, the hospital failed to ensure the nursing staff develops, and keeps current, a nursing care plan for 2 (#1, #2,) of 5 (#1-#5 sampled patient's records reviewed for care plans.

Findings:

A review of the hospital policy titled Nursing: Nursing Care Plan revealed in part:
A nursing care plan will be initiated within 24 hours of admission to the unit. The primary nurse is responsible for carrying out the care after reviewing the care plan and revising as needed.

A review of Patient #1's medical record failed to reveal a completed care plan.

In an interview on 06/08/2021 at 2:55 p.m. S1RNAdm reviewed the MR and verified the Plan of Care was not initiated and should have been initiated upon admission and revised throughout care.

A review of Patient #2's medical record failed to reveal a completed care plan.

In an interview on 06/10/2021 at 11:00 a.m. S1RNAdm verified the lack of a completed care plan for Patient #2.

Based on record review and interview, the facility failed to ensure all medical record entries were signed, dated and/or timed by the person responsible for providing the service for 3 (#3,4,5) of 5 (#1,2,3,4,5) patient records reviewed for completeness of medical records.

Findings:

A review of the hospital policy titled Nursing, Signing Verbal Orders revealed in part:
All verbal orders will be signed within 72 hours of documentation in the patient's medical record.
Nursing staff will flag each verbal order when documented in the medical record to alert the physician.
Orders that are not signed or flagged will be flagged by the night nurse during chart checks.
Physicians will check charts for flags, date and sign the verbal order then remove the flag when the order has been signed.

A review of Patient # 3's medical record revealed the Medications to be continued upon admission orders were received from S5NP by S8RN on 06/02/2021 at 4:30 p.m. but failed to reveal the medication orders were signed and dated S5NP.
Further review of Patient #3's medical record revealed an order dated 06/04/2021 7:30 p.m. Cleans intratagluteal skin ulcer with antibacterial solution hibicleanse, pat dry, apply banner cream apply sterile bordered gauze daily, VORB S6MD/S9RN, failed to reveal a physician signature within 72 hours.

In an interview on 06/09/2021 at 11:30 a.m. S1RNAdm verified the above information.


A review of Patient #4's medical record reveal an order dated 05/07/2021 at 3:59 p.m. as a TORB S5NP by S4RN and failed to reveal a signature and date by S5NP within 72 hours.

A review of Patient #4's orders dated 05/07/2021 at 6:45 p.m. and noted 05/07/2021 at 6:50 p.m. by S4RN failed to reveal a signature and date from the provider giving the orders.

In an interview on 06/10/2021 at 12:40 p.m. S1RNAdm verified the above findings.

A review of Patient #5's medical record revealed admission Orders dated 05/28/2021 at 9:00 p.m. as a telephone order from S5NP by S7RN and failed to reveal a signature and date by S5NP within 72 hours.

Further review of Patient #5's medical record revealed orders dated 05/03/2021 at 2:45 p.m. as telephone orders read back S5NP by S4RN but failed to reveal a signature and date within 72 hours by S5NP.

In an interview on 06/10/2021 at 1:30 p.m. S1RNAdm verified the information above.

Based on record review and interview, the hospital failed to ensure the receiver of patient verbal orders documented that the orders had been read back and verified for 3 (#3, 4, 5) of 5 sampled patient records reviewed for verbal orders.

Findings:


A review of Patient #3's medical record revealed orders for Medications to be continued upon admission orders were received from S5NP by S8RN on 06/02/2021 at 4:30 p.m. but failed to reveal the how the orders were received or clarification by S8RN.

Wound care order on admission:
06/02/2021 Sacrum pressure ulcer 1) clean with normal saline, pat dry, 2) apply bactroban and cover daily 06:00 am S5NP by S10RN on 06/02/2021 at 4:30 p.m.

Further review failed to reveal if order was verbal and read back for clarification by S10RN.

In an interview on 06/09/2021 at 11:30 a.m. S1RNAdm verified Patient #3's information above.

A review of Patient #4's medical record revealed physician orders dated 05/07/2021 at6:45 p.m. and noted by S5RN 05/07/2021 at 6:50 p.m. failed to reveal who gave the orders, documentation of clarification of the orders and no signature and date by provider.

In an interview on 06/10/2021 at 12:40 p.m. S1RNAdm verified the above findings.

A review of Patient #5's medical record revealed admission orders dated 05/28/2021 at 9:00 p.m. as a telephone order from S5NP by S7RN but failed to reveal the orders were clarified with S5NP.

In an interview on 06/10/2021 at 1:30 p.m. S1RNAdm verified the information above.

Based on observation and interviews the hospital failed to ensure outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use.

Findings:

An observation of the patient wound care cart the following items were noted to be available for patient use and expired or opened and not dated:

10 Xeroform Petrolatum 4x4 dressings expired 05/2021
2 Transparent 4x4 dressings expired 05/2020
1 Bottle Plain Packing Strip opened and not dated
1 Bottle HySept 25 % 473 ml opened and not dated
8 Maxorb Extra AG Silver Antimicrobial wound dressings expired 04/2020

In an interview on 06/09/ 2021 at 9:40 a.m. S2DON verified the above findings.

Based on observations and interviews, the hospital failed to maintain the physical plant and overall hospital environment in such a manner that the safety and well-being of patients was ensured.

Findings:

A tour of the hospital was conducted with S2DON between 10:00 a.m. and 11:57 a.m., who verified the findings as the tour was conducted.

1) Hallway
a) Lighting nonfunctional at the entrance way into the hospital from the main entrance;
b) Doorway at the end of the hallway was not closing, the handle was falling off the door, the bottom metal portion was noted to be damaged and the key pad control was noted to be hanging out the wall.
2) Patient room b
a) 2 ceiling tiles noted to have water damage
3) Patient room b
a) 1 over bed light not working
b) Water spot on ceiling tile over bed
4) Patient room c
a) 1 over bed light not functioning
b) Sheetrock repair not painted
5) Patient room d
a) Sheetrock repair not painted
b) Holes in bathroom wall near toilet
6) Room n Patient snack room
a) Light not functioning
7) Room o patient dining room
a) Lights not functioning
b) Water damage to wall near air conditioner
8) Patient room p
a) Over bed light not functioning
9) Patient room f
a) Over bed light not functioning
10) Patient room g
a) Over bed light not functioning
11) Patient room h
a) Bathroom ceiling tile and insulation falling down
b) Patched sheetrock not painted
12) Patient room i
a) Hole in bathroom wall
b) TV cable hanging out of the wall
c) Foot of bed trim held in place with exposed sharp nails
13) Patient room k
a) Sharp metal piece protruding on door frame
b) TV cable hanging from wall
c) Bathroom floor tile loose behind the toilet
14) Patient room l
a) Water damage behind toilet
b) Sheetrock damage
15) Patient room m
a) Door knob missing
b) Wall behind the toilet wet and buckled
c) Wall behind the bed with water damage
d) Dresser drawers falling off
16) Shower room
a) Sheet rock repairs not painted
b) Shower knobs missing

Based on record review, observation and interview, the hospital failed to ensure equipment was maintained in a manner to ensure an acceptable level of safety and quality as evidenced by: 1) Patient's rooms having a nurse call feature on the wall near the patient's bed and the patient bathrooms that was non- function for patient rooms a-m and portable call bells located in patient rooms were noted to ring as a different room at the nurse's station; 2) Biomedical services not being performed in the hospital on all equipment.

Findings:

1) Patient's rooms having a nurse call feature on the wall near the patient's bed and the patient bathrooms that was non- function for patient rooms a-m and portable call bells located in patient rooms were noted to ring as a different room at the nurse's station.

An observation of patient rooms and bathrooms a-m revealed wall mounted call bell cords which were nonfunctioning.

Further observation revealed portable call bells in patient rooms which when activated alerted as a different room nor did it match a cheat sheet on the wall in the nurse's station.

2) Biomedical services not being performed in the hospital on all equipment.

An observation of the only identifiable IV pump in the hospital revealed the next Biomedical due date as 04/10/2018.

In an interview on 06/09/2021 at 9:50 a.m. S2DON verified the above information.

Based on observations and interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented in accordance with hospital policy and acceptable standards of practice. This deficient practice was evidenced by the hospital:

1) Failed to ensure gloves were readily available for staff use
2) Failed to ensure expired food, opened undated food were not available for patient use
3) Failed to ensure the patient refrigerator was clean
4) Failing to ensure the walls were clean
5) Failed to ensure Surfaces were painted

Findings:

1) Failed to ensure gloves were readily available for staff use

An observation of patient rooms f,h,i,l and m failed to reveal gloves were readily available in or near the patient rooms.

2) Failed to ensure expired food, opened undated food were not available for patient use

An observation of the patient nourishment refrigerator revealed: open unlabeled orange drink, Glucerna expired June 1, 2021, opened undated Mayonnaise, ½ gallon opened milk expired April 2021

3) Failed to ensure the patient refrigerator was clean

An observation of the patient refrigerator revealed a brown substance on the interior door and shelves.

4) Failing to ensure the walls were clean

An observation of patient room n revealed a brown substance on the wall.

An observation of patient room m reveal a brown substance on the wall as well as the hallway outside of the room


5) Failed to ensure surfaces were painted and could be cleaned

A tour of the hospital between 10:00 a.m. and 11:57 a.m. revealed walls in the following patient rooms contained unpainted sheet rock: Shower room; Rooms c, d and i.

In an interview on 06/08/2021 at 11:15 a.m. S3CEO verified the above findings.