HospitalInspections.org

Based on observation, medical record review, policy review and staff interview, it was determined that the registered nurse (RN) failed to supervise and evaluate the nursing care for 3 of 4 patients (Patient #'s 2, 3 and 6) in the sample with wounds. Findings included:

The hospital policy entitled "Wound Assessment" stated, "...assessment of a wound will include at minimum location, size, tunneling undermining, drainage, odor, color and surrounding tissues...Measurement should include length, width and depth of the wound..."

The hospital policy entitled "Guidelines and Protocols, Clinical" stated, "...Wounds...Measurement and documentation of wounds...Documentation of Dressing Changes...status (Wound Progress Note)...Minimum Frequency...every 7 days...documented...completed weekly..."

The hospital "Job Description" for the "Wound Care Nurse (RN)" stated, "...Makes sure physician orders are written for all wound treatments and are placed on the chart in the order sheet..."

A. Patient #2
Medical record review revealed:

1. Right thigh wound photo, dated 2/17/20, documented wound measured 1.1 cm (centimeter) by 1.0 cm

2. No evidence of wound assessment or that the depth of the wound was measured on 2/17/20.

3. No evidence of wound assessment or measurement between 2/17 and 3/5/20 (17 days).

On 3/5/20 between 11:52 AM and 12:04 PM, Director A confirmed these findings.

B. Patient #3
Medical record review revealed:

1. Physician order, dated 2/27/20 for the gluteal (buttocks) wound be treated with ointment two times daily and left open to air

2. No evidence that the wound was assessed or treated on 2/29/20.

3. On the following dates, the nurse documented conflicting wound assessment information, both that the nurse changed the wound dressing (which was contrary to the physician order) and also that the wound was left open to air:
2/27, 2/28, 2/29 and 3/1/20

On 3/5/20 between 11:04 AM and 11:39 AM, Director A confirmed these findings.

C. Patient #6
1. During observation of wound care on 3/2/20 between 1:25 PM and 2:05 PM, RN A (Wound Care Nurse) applied MediHoney to the patient's sacral flap wound.

2. Medical record review revealed:
a. Physician order dated 2/25/20 for the following sacral flap wound care:
- normal saline cleanse, skin prep peri (around) wound, xeroform to flap sutures, cover with dressing

b. No physician order for the application of MediHoney.

During an interview on 3/5/20 at 11:41 AM, Director A:
- confirmed these findings
- reported that the nurse should not have applied MediHoney to the wound on 3/2/20

Based on medical record review, policy review and staff interview, it was determined that for 2 of 10 patients (Patient #'s 3 and 4) in the sample, the physician failed to authenticate verbal orders within 72 hours as required by hospital policy. Findings included:

The hospital "Medical Staff Bylaws" stated, "...The responsible physician...shall authenticate, time, and date all orders promptly, within the time frame specified by state law, including scope of practice laws, hospital policies..."

The hospital policy entitled "Concurrent Analysis of Medical Records" stated, "...Telephone and Verbal orders must be authenticated within the timeframe specified...authenticated within 72 hours of the order given..."

Medical record review revealed:

A. Patient #4
The physician failed to authenticate the following verbal orders within 72 hours as required by hospital policy:

1. Order dated 1/9/20 at 10:17 AM for soft wrist restraints was signed by the physician on 1/12/20 at 2:01 PM (exceeded by 3 hours).

2. Order dated 1/13/20 at 4:22 AM to discontinue soft wrist restraints was signed by the physician on 1/20/20 at 4:39 PM (exceeded by 84 hours).

These findings were confirmed by Chief Nursing Officer A on 3/2/20 at 12:24 PM.

B. Patient #3
As of review on 3/5/20, the physician failed to authenticate the following verbal orders within 72 hours as required by hospital policy:

a. Orders dated 2/28/20:
4:18 PM: Thera M Plus (multivitamin)
4:18 PM and 4:46 PM: 2 nutritional supplements

These orders exceeded the 72 hour limit for authentication by 66 hours.

b. Order dated 2/29/20:
2:38 PM: telemetry monitoring

The order exceeded the 72 hour limit for authentication by 44 hours.

On 3/5/20 at 11:37 AM, Director A confirmed these findings.

Based on review of documents, policy review and staff interview, it was determined that for 2 of 2 medication rooms on the unit where refrigerated medications were stored, staff failed to check and document refrigerator temperatures to ensure the safety and well-being of patients. Findings included:

The hospital policy entitled "Drug Storage" stated, "To promote efficient, safe storage of pharmaceuticals...All drugs must be stored in a temperature-controlled environment. Temperatures will be documented daily..."

On 3/4/20 at 10:05 AM, review of "Medication Refrigerator Log" forms for the South and North medication rooms revealed temperatures were not monitored and recorded daily as required on the following days:

A. South Medication Room:
- 7/24 and 8/31/19
- 2/1, 2/2 and 2/3/20

B. North Medication Room:
- 5/16, 7/17, 7/24, 7/27, 7/28, 8/11, 10/20, 10/24, 10/25 and 12/20/19
- 1/3, 2/1, 2/2 and 2/3/20

These findings were confirmed by Chief Executive Officer A on 3/4/20 at 10:33 AM.

Based on observation, policy review and staff interview, it was determined that for 28 of 28 current patients, the hospital failed to ensure that facilities were maintained to ensure an acceptable level of safety, quality and cleanliness. Findings included:

The hospital policy entitled "Routine Daily Cleaning and Disinfection" stated, "...General Principles...All patient rooms, clinical support and ancillary areas will be cleaned daily...housekeeping staff will clean everything in the patient room...Spot clean cabinets and walls...Periodic Cleaning...Walls are thoroughly washed semi-annually or as necessary...vents (interior) are dusted weekly or as necessary..."

During an environmental tour of inpatient areas of the hospital on 3/2/20 between 9:11 AM and 10:39 AM, the following observations were made and confirmed by Chief Nursing Officer A at the time of the finding:

1. Patient Room #507, #510 and #512
- dusty and rusted air vent

2. Patient Room #509
- dusty air vent

3. Patient Room #511
- blistered/bubbled paint on the wall by the handwashing sink

4. Patient Room #513
- dusty air vent

5. Patient Room #515
- cracked drywall
- dusty air vent

6. Patient Room #517
- dusty air vent

7. Patient Room #518 and #519
- dusty air vent
- chipped wall paint

8. Patient Room #521
- dusty air vent

9. Patient Room #523 and #524
- cracked drywall
- dusty air vent

10. Patient Room #531, #534 and #535
- chipped wall paint

11. Patient Room #537
- dusty air vent

12. Physical Therapy Room
- dust on parallel bars platform

Based on observation, policy review, medical record review and staff interview, it was determined that for 5 of 26 patients (Patient #'s 6, 10, 15, 17 and 20) observed on 3/2/20, the infection control officer failed to ensure that staff adhered to infection control measures. Findings included:

The Director of Quality Management "Job Description" stated, "...The Director of Quality Management is responsible for coordination, development and evaluation of all outcome activities including...Infection Control...Implements IC (infection control) plan..."

During interview on 3/2/20 at 10:08 AM, Chief Executive Officer (CEO) A reported that the position of Director of Quality Management, as related to Infection Control responsibilities, was currently being covered by Chief Nursing Officer (CNO) A.

The hospital policy entitled "U02-N Urinary Catheter (UC) Management" stated, "...A sterile, continuously closed drainage system should be maintained for indwelling and suprapubic catheter systems...Keep the drainage bag...off the floor..."

The hospital policy entitled "Policy: IC 4-5" stated, "...Diseases requiring Contact Precautions ...any MDRO (multi-drug resistant organism)...Clostridium difficile colitis...private room is needed...use...Precautions sign...PPE (personal protective equipment) will be available at the entrance to the room...Gowns should be worn...Visitors should be limited and informed of the purpose of the isolation...should be instructed on the use of gowns, gloves and proper hand hygiene..."

The hospital policy entitled "IC 4-2 Hand Hygiene" stated, "...Effective hand hygiene is...basis for an effective Infection Control Program...hand hygiene...Before and after every patient contact...When moving from high contamination patient care activities to cleaner activities/if moving from a contaminated body site to a less contaminated body site...After removing gloves. After any contact with...dressings...Before...medication administration..."

The hospital policy entitled "IC 4-4 Standard Precautions" stated, "...Gloves...worn when giving direct patient care that may result in blood...exposure...Gloves will be changed after every patient contact, when moving from dirty to clean task..."

A. During a hospital tour conducted with CNO A on 3/2/20 between 9:11 AM and 10:05 AM, the urine collection bag and spigot were observed touching the floor for the following patients with urinary catheters:

- Patient #'s 10, 17 and 20

B. The following was observed on 3/2/20 between 3:50 PM and 3:58 PM, during IV (intravenous) medication administration to Patient #15, performed by Registered Nurse (RN) B:

- sanitized hands
- donned gloves
- prepared IV medication bag
- attached IV tubing to medication bag
- touched IV pump
- with gloved hand, reached into nurse uniform pocket and removed 2 packets of alcohol pads
- placed alcohol packets on bed
- retrieved and opened packet
- disconnected patient's IV cap
- used alcohol pad to disinfect IV hub
- attached medication tubing to IV hub

RN B failed to change gloves/sanitize hands:
- after moving from a dirty task (reaching inside nurse pocket)
- before administration of the IV medication

This finding was confirmed with RN B on 3/2/20 at 3:58 PM.

C. Patient #6

1. Medical record revealed:
2/28/20 "Nursing Note": contact precautions were initiated and patient was placed on IV medications for Clostridium difficile colitis.

2. On 3/2/20 at 1:45 PM:
- A visitor was observed in Patient #6's room and seated next to Patient #6's bed.
- The visitor was not wearing PPE (no gown or gloves).
- A Contact Precautions sign was posted at Patient #6's door.
- RN A reported that Patient #6 was on contact precautions for Clostridium difficile colitis.

These findings were witnessed and confirmed by both RN A and Case Manager A on 3/2/20 at 2:15 PM.

On 3/2/20 at 3:38 PM, CNO A reported:
- spoke with Patient #6's visitor after the finding was confirmed and the visitor reported he/she had not been instructed on the use of gowns, gloves and proper hand hygiene
- was provided instruction during their conversation

3. On 3/2/20 between 2:05 PM and 2:25 PM, the following was observed as RN A provided wound care to Patient #6 (on contact isolation precautions):

- donned gloves
- performed sacral wound care and covered wound with dressing
- with same gloves on, reached into uniform pocket, pulled out pen and signed/dated dressing
- returned pen into uniform pocket

RN A failed to change gloves/perform hand hygiene after completing dressing change and before reaching inside nurse pocket.

These findings were confirmed with RN A on 3/2/20 at 2:25 PM.