HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the patient's representative who had filed a grievance was notified, in writing, of the contact person, the steps taken to investigate the grievance, the results of the grievance process, and the date of completion for 1 (#4) of 1 sampled patient grievance investigations reviewed.

Findings:

Review of the requested hospital grievances from 1/2017- 4/2018 revealed a grievance had been filed regarding care received by Patient #4 during the patient's stay at the hospital. Further review of the grievance investigation revealed no documented evidence that a written response had been provided to the complainant upon resolution of the grievance/completion of the investigation.

In an interview on 4/17/18 at 12:32 p.m. with S2DON, he confirmed no written response had been provided to the complainant upon completion of the grievance investigation involving Patient #4's care. S2DON reported S1CEO had spoken with the complainant, in person, but confirmed no written response had been provided to the complainant upon completion of the investigation regarding complaints about the care received by Patient #4 during the patient's hospitalization.

Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by:

1) Failure to document an assessment of a patient's skin condition (a fungal rash), as per hospital policy, for 1(#2) of 5 (#1-#5) sampled patients reviewed.

2) Failure to obtain weights as ordered by the physician for 1(#4) of 5 (#1-#5) sampled patients reviewed.

Findings:

1) Failure to document an assessment of a patient's skin condition as per hospital policy.

Review of the hospital policy titled,"Patient Turning Schedules" Policy number: NP-124, revealed in part: Guidelines: Initially all rehabilitation patients with sensory and/or motor impairment will be assisted to turn at least every 2 hours while in bed with skin condition assessed once a shift. Nursing staff is to monitor patient skin for redness/pressure areas/pressure sores.

Review of Patient #2's medical record revealed an admission date of 12/21/17 and a discharge date of 2/9/18. Further review revealed an admission diagnosis of continuum of care (intravenous antibiotics for a minimum of 6 weeks) for Proteus Mirabalis tissue infection in right knee. Additional review revealed the patient had a co-morbid diagnosis of Osteoarthritis (knees bilaterally) and was obese, chronically deconditioned, non-weight bearing, and in a wheelchair.

Review of Patient #2's physician's orders revealed an order, dated 1/11/18 at 10:00 p.m., for Nystatin powder to abdominal folds BID (twice a day) and Nystatin cream to peri-rash BID.

Review of Patient #2's MAR revealed the Nystatin cream and Nystatin powder were documented as being administered as ordered BID (at 9:00 a.m. and 9:00 p.m.) from 1/12/18 through 2/9/18.

Review of Patient #2's physician progress notes revealed the patient's rash was documented as a fungal dermatitis.

Review of Patient #2's nurses' notes from 12/21/17 - 2/9/18 revealed no documented evidence of nursing assessment/documentation of the patient's rash/skin assessments other than assessment of the presence of the patient's knee wound/wound vac.

In an interview on 4/17/18 at 8:24 a.m. with S2DON, he confirmed, after review of Patient #2's physician's progress notes, that the patient had a fungal rash. S2DON also confirmed, after review of Patient #2's entire medical record, there was no nursing documentation of an assessment of the patient's rash from 1/10/18 through 2/9/18 (date of discharge), in the nurses notes or anywhere in the medical record. S2DON agreed the patient's skin/skin rash should have been assessed every shift.



2) Failure to obtain weights as ordered by the physician.

Review of the hospital policy titled, "Height and Weight Measurement", dated 1988, revealed staff was to document date, time, height, and weight.

Review of Patient #4's medical record revealed she was a 64 year old who had been admitted to a local Emergency Department with bilateral lower extremity edema (swelling) and shortness of breath caused by acute and chronic volume overload. She also had a paracentesis (a needle placed in the abdomen to remove fluid accumulation). Patient #4 was then admitted to this hospital on 4/28/17 with a diagnosis in-part of chronic diastolic heart failure. The patient was discharged on 5/20/17.

Review of Patient #4's physician's order sheet revealed an order dated 5/1/17 at 11:24 a.m. for weights to be done every other day. Further review revealed an order dated 5/3/17 at 9:00 a.m. to please notify DON of no weights to chart despite order written 5/1/17.

Review of Patient #4's medical record revealed weights were documented on 4/28/17, 5/4/17, 5/6/17, 5/8/17 and 5/12/17. No documentation of weights could be found for 5/1/17, 5/2/17, 5/3/17, 5/10/17. Further review revealed no weights were recorded between 5/12/17 and 5/20/17.

In an interview on 4/17/18 at 12:14 p.m. with S2DON, he verified the weights on Patient #4 had not been completed as ordered by the physician, but should have been.


39791

Based on interview, the hospital failed to ensure "near miss" medication errors that did not cause patient harm, but could indicate system vulnerabilities that must be addressed in order to avoid events that could result in harm, were collected, tracked and trended for patient Quality Assurance and Performance Improvement (QAPI).

Findings:

In an interview on 4/17/18 at 11:50 a.m. with S4Pharmacist, he confirmed that he collected medication variance information and participated in the hospital's Pharmacy and Therapeutics committee meetings. S4Pharmacist confirmed he did not collect "near miss" data as part of the medication variance data collection.

In an interview on 4/17/18 at 12:30 p.m. with S2DON, he confirmed "near misses' were not included in the hospital's medication variance tracking and trending.

Based on observations, record reviews, 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 as evidenced by:

1) failure to ensure staff compliance with Droplet isolation precautions for 1 (# 3) of 2 (#1, # 3) isolation patients observed; and
2) failure to ensure stock topical creams, ointments, and gels stored in the hospital's wound care supply cart were labeled with date and time of opening.


Findings:

1) Failure to ensure staff compliance with Droplet isolation precautions.

Observation on 4/16/18 at 11:45 a.m. revealed Patient #3 had a droplet precaution sign on his hospital room door and an isolation cart next to the door. S3RN was observed exiting Patient #3's room with a glove on her left hand holding what appeared to be a lab tube containing blood (not in a biohazard bag). S3RN then entered the medication room and no hand washing was observed.

Observation on 4/16/18 at 11:47 a.m. revealed S5RT exited Patient #3's room with a clipboard in his hand. S5RT then entered the nursing station and placed clipboard on the counter.

In an interview on 4/17/18 at 12:15 p.m. with S2DON, he verified Patient #3 was on droplet precautions and stated S3RN should not have exited Patient #3's room with a tube of blood in her hand due to biohazard bags being stored in patient rooms. S2DON also stated clipboards should not go into isolation rooms.


2) Failure to ensure stock topical creams, ointments, and gels stored in the hospital's wound care supply cart were labeled with date and time of opening.

Observation of the hospital's wound care supply cart on 4/17/18 at 11:10 a.m. revealed the following opened, unlabeled stock topical creams, ointments, and gels:
1-10 gram tube of Iodosorb iodine gel opened, unlabeled with date/time of opening;
2- 30 gram Nystatin cream tubes opened, unlabeled with date/time of opening;
3- 45 gram tubes of Betamethasone cream opened, unlabeled with date/time of opening;
1 - 30 gram tube of Santyl enzymatic debriding ointment opened, unlabeled with date/time of opening;
1- 22 gram tube of Bactroban ointment opened, unlabeled with date/time of opening;
1-15 gram tube of Triple Antibiotic ointment opened, unlabeled with date/time of opening;
1-15 gram tube of Mupirocin ointment opened, unlabeled with date/time of opening; and
3- 45 gram tubes of Metronidazole ointment opened, unlabeled with date/time of opening.

The above referenced findings were confirmed, in interview, with S3RN during the observation of the wound care cart on 4/17/18 at 11:10 a.m. S3RN agreed the tubes should have been dated and timed when opened.



39791