HospitalInspections.org

This condition level deficiency was cited based on review of medical records, facility policies and procedures and staff interviews, it was determined the nursing staff failed to:

1) Identify, assess and document all wounds.

2) Perform and document ordered wound care.

3) Obtain and document daily weights as ordered.

4) Ensure each patient's Plan of Care was complete and up to date to meet the patients' needs.

5) Prepare and administer medications according to the facility's policies.

These deficient practices affected 6 of 6 medical records reviewed and 2 patient observations of medication administration and has the potential to negatively affect all patients admitted to this facility.

Findings include:

Please refer to A392, A396 and A405 for findings.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to affect all patients served by the hospital.

Findings include:

Refer to Life Safety Code violations for findings.

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

a) Identify, assess and document all wounds.

b) Perform and document ordered wound care.

c) Obtain and document daily weights as ordered.

This affected 6 of 6 medical records reviewed including Patient Identifier (PI) # 3, PI # 4, PI # 1, PI # 2, PI # 5, PI # 6 and had the potential to affect all patients admitted to the facility.

Findings include:

Policy: Assessment of the Patient
Policy Number: 20-03004
Effective Date: 10/01/2014

Policy

"II. Shift Assessment & Re-assessment

A focused shift physical assessment is to be performed by the licensed nurse every 4 hours for critical patients... and every 12 hours for medical surgical patients. Patient care activities, interventions, and responses to care are to be documented by licensed nurses on the Nurses 24 Hour Assessment and Progress Record. A re-assessment will be performed as needed and documented if the patient's condition changes or as necessary when procedures/treatments are performed.

III. An opening and closing narrative should be documented during the shift. Entries should be made every 4 hours or more often as necessary...

IV. Plan of Care

The nursing plan of care (included within the multidisciplinary Plan of Care) will be developed by the RN based on the findings of the admission assessment. The nursing plan of care is to be developed within the first 24 hours of the patient's stay. The plan of care is to be individualized based on the patient's needs for nursing care. A nursing plan of care will be initiated...with evaluations, revisions, or updates documented...on a weekly basis or more often as needed.

Policy: Pressure Ulcers, Wound Assessment and Staging
Policy Number: 20-03055
Effective Date 10/01/14

Guidelines:

1. The wound care nurse will see all patients for an initial and weekly assessment of all wounds and staging of pressure ulcers...
2. In the absence of the wound nurse, a certified RN (Registered Nurse) and/or LPN (Licensed Practical Nurse) can assess wounds, stage pressure ulcers and determine as to whether wounds are present on admission...documentation will include, at minimum, the following:
a. Wound location
b. Description of wound bed
c. Drainage (if present)
d. Type of wound
e. Stage (if pressure ulcer)
f. Measurements

1. PI # 3 was admitted to the facility on 11/7/16 with diagnoses including Small Bowel Obstruction with Resection on 11/1/16.

Review of the physician's orders revealed the following wound care order dated 11/9/16 at 1550 (3:50 PM): Cleanse abdominal wound with NS (normal saline) - skin prep and window peri wound - approximate wound edges while filling wound bed with a strip of black foam - suction at 125 mm Hg (millimeters of mercury) - change MWF (Monday, Wednesday, Friday).

Review of the nursing documentation in the MR dated 11/11/16 (Friday) revealed the floor nurse documented the wound VAC (vacuum assisted closure) device was changed by the WCN (wound care nurse). Review of all the documentation by the WCN revealed no documentation the wound care was completed on 11/11/16.

An interview was conducted on 11/16/16 at 10:30 AM with Employee Identifier (EI) # 1, Director of Operations, who confirmed there was no documentation the WCN performed the ordered wound care on 11/11/16.

2. PI # 4 was admitted to the facility on 10/27/16 with diagnoses including Right Arm Cellulitis, Respiratory Failure and Open Abdominal Wound.

Review of the MR revealed a physician's order dated 10/28/16 for daily weights, and an order for wound care dated 11/9/16 at 10 AM as follows:
Santyl to wound bed Q WV (every wound vacuum) change on abd (abdomen) and arm - cover with Adaptic - Fill wound bed with black foam - suction at 125 mm Hg continuous - all other wound care orders as previously written.

Further review of the MR revealed an order dated 11/9/16 at 11:22 AM as follows: Place white foam over the bottom L (left) corner of the abdominal wound to prevent fistula formation.

Review of the MR revealed no documentation the daily weights were obtained.

Review of the WCN documentation and the TAR (Treatment Administration Record) revealed the wound VAC was to be changed on MWF.

Review of the WCN documentation and treatment note dated 11/11/16 revealed no documentation the Santyl was applied to the wound bed nor that white foam was applied to the abdominal wound to prevent fistula formation.

An interview was conducted on 11/16/16 at 9:00 AM with EI # 1, who confirmed there was no documentation the daily weights were obtained and no documentation the Santyl was applied by the WCN on 11/11/16.



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3. PI # 1 was admitted to the facility on 10/27/16 with diagnoses including Metabolic Acidosis, Acute Aphasia and Encephalopathy.

Review of the Nurse's 24 Hour Assessment & Progress Record dated 10/28/16 at 7:40 AM revealed the nurse documented patient had a wound located on the right thigh with a dressing that was clean, dry, intact and a wound to the sacral area and the WCN was notified. There was no further documentation related to these wounds or the dressing to the right thigh until 2:00 PM, which was 6 hours later.

Review of the Nurse's 24 Hour Assessment & Progress Record dated on 10/28/16 at 2:00 PM, the nurse documented the wound care nurse was at bedside and applied wound VAC (Vacuum assisted closure) device to the right thigh wound. There was no documentation by the WCN provided wound care to the right thigh, nor was there documentation of an assessment of either the wound to the right thigh or sacral areas.

Review of the Physician's Order dated 10/28/16 at 2:55 PM revealed orders to apply skin prep and place Mepilex border over the wound bed to the sacral wound and to apply Lantiseptic to the patient's buttocks twice a day and PRN (as needed) and to cleanse the wound to the right inner thigh with NS (Normal Saline), apply skin prep to the periwound area, fill the wound bed with black foam and apply suction at 125 mmHg (millimeters/Mercury) to be changed on Monday, Wednesday and Friday.

Review of the Nurse's 24 Hour Assessment & Progress Record dated on 10/28/16 at 8:45 PM the nurse documented having applied Mepilex to the buttocks. There was no further documentation of the patient's wound or the dressing to the buttock/sacral area until 10/30/16 at 1:00 AM, when the nurse documented the Mepilex dressing to the coccyx for skin protection.

The next documentation related to the patient's wound or the dressing to the buttock/sacral/coccyx area was on the Nurse's 24 Hour Assessment & Progress Record dated 10/30/16 at 7:10 PM, which was 6 hours and 10 minutes later from 10/30/16 at 1:00 AM to 10/30/16 at 7:10 PM. There was no documentation the day shift staff assessed patient's wound or the dressing to the buttock/sacral/coccyx area.

Review of the Physician's Order dated 10/31/16 (Monday) revealed orders to apply skin prep to bilateral heels, apply Tegaderm foam adhesive dressings to be changed every three days and PRN.

Review of the Nurse's 24 Hour Assessment & Progress Record dated 10/31/16 revealed no documentation in the Daily Wound Assessment of the wounds or the wound VAC to the right thigh or the wound and/or dressing to the buttocks/sacral/coccyx area.

Review of the WCN documentation signed and dated 10/31/16 at 3:52 PM by the nurse revealed the patient had wounds to the right thigh, bilateral buttocks and bilateral heels.

Review of the Nurse's 24 Hour Assessment & Progress Record dated 10/31/16 revealed no further documentation of an assessment of the wounds or dressings to the buttocks or bilateral heels.

Review of the Nurse's 24 Hour Assessment & Progress Record dated 11/2/16 revealed no further documentation of an assessment of the wounds or dressings to the buttocks or bilateral heels.

Review of the Nurse's 24 Hour Assessment & Progress Record dated 11/3/16 revealed no documentation of an assessment of the wounds or dressings to bilateral heels.

Review of the Nurse's 24 Hour Assessment & Progress Record dated 11/5/16 revealed no documentation of an assessment of the wounds or dressings to the buttocks from 7:00 AM to 8:30 PM or the wounds or dressings to bilateral heels in the 24 hour period.

Review of the Nurse's 24 Hour Assessment & Progress Record dated 11/6/16 revealed the first documentation of an assessment of the wounds or dressings to the buttocks or bilateral heels was at 11:50 AM. The nurse assessed the dressing to the buttock area on 11/6/16 at 9:30 PM. The next documentation of an assessment of the wounds to the coccyx and bilateral heels was on the Nurse's 24 Hour Assessment & Progress Record dated 11/7/16 at 8:00 PM, which was 22 hours and 30 minutes (coccyx) and 32 hours and 10 minutes (bilateral heels).

The next documentation by the nursing staff related to the wound to the coccyx area was on the Nurse's 24 Hour Assessment & Progress Record dated 11/8/16 at 8:00 AM, which was 12 hours later. There was no documentation of an assessment of the wounds or dressings to the bilateral heels at that time.

The next documentation of the patient's wounds was documented on the Nurse's 24 Hour Assessment & Progress Record dated 11/10/16 at 8:00 AM, (24 hours later), which the nurse documented the Mepilex was on the bilateral buttocks and the right and left heels were deep tissue injuries.

The next documentation of the patient's wounds to the coccyx was documented on the Nurse's 24 Hour Assessment & Progress Record dated 11/11/16 at 10:50 AM (26 hours and 50 minutes) at which time, the nurse documented having placed a duoderm to the coccyx area. There was no documentation of a physician's order for the use of duoderm. There was no documentation at that time of an assessment of the wounds to bilateral heels.

Review of the Nurse's 24 Hour Assessment & Progress Record dated 11/12/16 revealed no documentation of an assessment of the wound or dressing to the patient's sacral area.

Review of the Nurse's 24 Hour Assessment & Progress Records and Treatment Administration Records revealed no documentation Lantiseptic was applied to the patient's buttocks twice a day on 10/29/16, 10/30/16, 10/31/16, 11/1/16, 11/2/16, 11/3/16, 11/4/16, 11/5/16, 11/6/16, 11/7/16, 11/8/16, 11/9/16, 11/10/16, 11/11/16, 11/12/16 and 11/13/16.

Review of the Nurse's 24 Hour Assessment & Progress Records and Treatment Administration Records revealed no documentation of wound care to the sacral area on 10/30/16, 10/31/16, 11/1/16, 11/2/16, 11/3/16, 11/4/16, 11/5/16, 11/7/16, 11/8/16, 11/9/16 and 11/10/16.

Further review of the Nurse's 24 Hour Assessment & Progress Records, Treatment Administration Records and the Wound Care nurse's documentation dated 10/31/16 to 11/12/16 revealed the only documentation of wound care to bilateral heels was completed on 10/31/16 and then on 11/12/16.

An interview was conducted on 11/16/16 at 8:50 AM with EI # 3, Director of Clinical Services, who verified the above findings.

4. PI # 2 was admitted to the facility on 10/25/16. Review of the Physician's Orders dated 10/26/16 at 2:32 PM revealed orders to cleanse the wound to the coccyx area with NS, apply skin prep, cover sacrum and coccyx with Mepilex border and to change every three days and PRN.

Review of the Physician's order dated 10/27/16 at 10:40 AM revealed orders for the dressing to the abdominal wound to be changed every 8 hours as follows: cleans with Hibiclens and replace dry gauze and secure with minimal tape.

Review of the Nurse's 24 Hour Assessment & Progress Records and Treatment Administration Records dated 10/27/16 revealed the nurse documented having performed wound care to the abdomen at 11:50 AM. There was no documentation of the specific wound care performed to the abdominal wound, nor was there documentation of an assessment of the wound or the dressing to the coccyx/sacral area. The only other documentation of wound care provided to the abdomen was at 3:00 PM, then on 10/28/16 at 2:30 AM, not every 8 hours as ordered by the physician.

Review of the Nurse's 24 Hour Assessment & Progress Records and Treatment Administration Records dated 10/28/16 revealed wound care was provided to the abdominal wound at 2:30 AM, 10:00 PM then on 10/29/16 at 6:00 AM, not every 8 hours as ordered by the physician. There documentation of an assessment of the wound or the dressing to the coccyx/sacral area.

Further review of the Nurse's 24 Hour Assessment & Progress Records and Treatment Administration Records dated 10/28/16 revealed the nurse documented a duoderm was intact to the coccyx. There was no documentation of a physician's order for the use of duoderm.

Review of the Nurse's 24 Hour Assessment & Progress Records and Treatment Administration Records dated 10/29/16 revealed the only documentation wound care was performed to the abdominal wound was completed at 2:00 PM, not every 8 hours as ordered by the physician. There was no documentation the nurse assessed the wound and/or dressing to the coccyx/sacral area in the 24 hour period.

An interview was conducted on 11/16/16 at 8:20 AM with EI # 3, who verified the above findings.

5. PI # 5 was admitted to the hospital on 11/7/16 with a diagnosis of Acute Respiratory and Renal Failure. A review of the initial nursing assessment dated 11/07/16 at 5:30 PM, revealed documentation PI # 5 had "...small reddened area on sacral area." At 8:30 PM, nursing staff documented in the narrative note, "...several small red areas with broken skin noted to sacral area." At 11:30 PM, nursing staff documented in the narrative note, "Buttocks has pink open areas."A physician order dated 11/8/16 was for Lantiseptic to buttocks and perineum twice a day and as needed.A review of the wound care nurse documentation dated 11/8/16 documented the following:Wound number 1: Location: Buttocks - bilateralWound type: PressureWound stage: IIWound size: (L) 5.0, (W) 10.0, (D) 0.0Current treatment for this wound was documented as: Lantiseptic to buttocks and perineum twice a day and as needed. Turn patient every two hours. Wound number 2:Location: Buttocks - bilateralWound type: other - excoriationWound degree: partial thicknessCurrent treatment for this wound was documented as: Lantiseptic to buttocks and perineum twice a day and as needed. Turn patient every two hours. A review of the nursing 24 hour assessment and progress record daily wound assessment was reviewed for the following dates: 11/8/16, 11/9/16 and 11/10/16. There was no documentation by nursing staff on these days related to the wounds identified on admission, interventions provided or the treatments that were provided.On 11/16/16 at 7:45 AM, in an interview with EI # 3, the above information was confirmed. Hospital staff were asked where nursing staff should document wounds and confirmed in the daily wound assessment section of the nursing flowsheet.

6. PI # 6 was admitted to the hospital on 11/4/16 with diagnosis of Congestive Heart Failure, Acute Chronic Renal Failure, Diabetes, and left Below the Knee Amputation (BKA).

A review of the physician orders dated 11/7/16 at 4:40 PM and 5:05 PM, revealed the following wound care orders:

4:40 PM:
Cleanse left knee and right foot with normal saline. Cover with Xeroform gauze (A sterile, fine mesh gauze impregnated with a blend of 3% Bismuth Tribromophenate (Xeroform) and USP Petrolatum. (www.deroyal.com )

5:05 PM:
Cleanse right ankle wound with normal saline. Cover with a Mepilex border. Change the dressing daily.
Lantiseptic to buttock, thighs and inguinal folds with twice a day at 9:00 AM and 9:00 PM.
Resinol to buttocks, thigh and inguinal folds twice a day at 2:00 AM and 2:00 PM.
Turn patient from right to left every 2 hours - do not allow patient to lie flat on (his/her) back.
Right heel protector at all times - float heel and foot.
A review of the physician order dated 11/8/16 at 1:22 PM, revealed the following wound care orders: Cleanse left stump staples with normal saline and leave open to air daily.
A review of the wound care nurse documentation revealed the following:

Wound number 1:
Date of assessment: 11/7/16
Wound location: Right lateral distal ankle (malleolus)
Wound type: arterial
Wound degree: partial thickness
Wound size: (L) 1.7; (W) 1.5; (D) 0.1
Special instructions: Patient has a necrotic right ankle wound. This wound is circular thus appears to be an arterial wound.

Current treatment: Cleanse right ankle wound with normal saline. Cover with a Mepilex border. Change the dressing daily. Patient is to wear a right heel protector at all times. Float heel and foot.

Wound number 2:
Date of assessment: 11/7/16
Wound location: Bilateral Buttocks
Wound type: Pressure
Wound stage: II (two)
Wound size: (L) 8.0; (W) 12.0; (D) 0.0
Special instructions: Patient has multiple areas of breakdown on bilateral buttocks and posterior thighs. These areas present as excoriation but the presence of yellow slough on her buttocks is also evidence of pressure injury.

Current treatment: Lantiseptic to buttock twice a day at 9:00 AM and 9:00 PM and as needed for increased redness. Resinol to buttocks twice a day at 2:00 AM and 2:00 PM. Turn patient from side to side. Do not allow patient to lie flat on (his/her) back.

Wound number 3:
Date of assessment: 11/7/16
Wound location: Right Buttocks
Wound type: open lesion
Wound degree: partial thickness
Special instructions: Patient has many areas of excoriation on bilateral buttocks and posterior thighs. This will be treated aggressively to heel these wounds and prevent further breakdown.

Current treatment: Lantiseptic to buttocks twice a day at 9:00 AM and 9:00 PM and as needed for increased redness. Resinol to buttocks twice a day at 2:00 AM and 2:00 PM. Turn patient from side to side. Do not allow patient to lie flat on (his/her) back.

Wound number 4:
Date of assessment: 11/7/16
Wound location: Left knee (medial knee)
Wound type: Surgical
Wound degree: full thickness
Wound stage: not applicable.
Special instructions: Patient has had a recent left below the knee amputation. The staples are intact, the wound is well approximated without redness, edema or drainage.

Current treatment: Cleanse staples with normal saline daily and leave open to air.
Wound number 1:
Date of assessment: 11/8/16
Wound location: right heel
Wound type: non-wound
Wound number 2:
Date of assessment: 11/8/16
Wound location: left knee (medial knee)
Wound type: Surgical
Wound degree: Full thickness
Special instructions: Patient has a recent left below the knee amputation. The staples are intact.
Current treatment: Cleanse staples with normal saline daily and leave open to air.
A review of the medical record revealed nursing staff failed to document:
On the Medication Administration Record (MAR) dated 11/5/16 to 11/6/16 the 9:00 AM dose of Santyl ointment was applied to the wound and 9:00 PM dose of Xenaderm ointment was applied to the wound.
On the MAR dated 11/8/16 to 11/9/16 the 9:00 AM dose of Xenaderm ointment and Santyl ointment was applied to the wound.
On the MAR dated 11/11/16 to 11/12/16 the 2:00 AM and 2:00 PM doses of Vasolex and Lidocaine ointments were applied to the wounds.
A review of the Treatment Administration Record (TAR) was reviewed. The TAR listed the following treatments that nursing staff were to provide to PI # 6's wounds:

1. Right ankle: cleanse wound with normal saline; cover with Mepilex border; change the dressing daily; heel protectors at all times. There was only documentation on the TAR this was done on 11/7/16 and 11/9/16.

2. Lantiseptic to buttocks at 9:00 AM and 9:00 PM. There was only documentation on the TAR this was done once a day, not twice a day as ordered, on 11/7/16, 11/8/16 and 11/9/16.

3. Resinol to buttock at 2:00 AM and 2:00 PM. There was only documentation on the TAR this was done once a day, not twice as day as ordered, on 11/7/16, 11/8/16, and 11/11/16.

A review of the nurses 24 hour assessment and progress record revealed the following:

On 11/5/16 the daily wound assessment section documented three wounds located at: left hip, coccyx and left below knee amputation (BKA) incision. The only intervention documented was the site was checked and the dressing was clean, dry and intact at 8:00 PM. No other documentation was noted on the daily wound assessment.

On 11/6/16 the daily wound assessment section documented four wounds located at: left hip, buttocks, left BKA and right ankle. The only intervention documented was the site was checked and the dressing was clean, dry and intact for the left BKA wound at 8:00 AM and 10:00 AM. No other documentation was noted on the daily wound assessment.

On 11/7/16 the daily wound assessment section documented three wounds located at: left BKA, right ankle and lower back. The interventions documented for the left BKA and lower back at 3:00 PM, 7:00 PM, 11:00 PM, and 3:00 AM were for site checked and dressing clean dry and intact. The wound for the right ankle documented a dressing change "per (name of wound care nurse)" at 3:00 PM. There was no other documentation noted on the daily wound assessment.

On 11/8/16 the daily wound assessment section documented only one wound located at the right heel. No other wounds were addressed or documentation to show what interventions had been provided by nursing staff.

On 11/9/16 the daily wound assessment section documented only one wound located at the right heel. No other wounds were addressed or documentation to show what interventions had been provided by nursing staff.

On 11/10/16 the daily wound assessment section documented only one wound located at the left BKA. No other wounds were addressed or documentation to show what interventions had been provided by nursing staff, other than the 9:00 PM, 11:00 PM, 1:00 AM, 3:00 AM and 5:00 AM, site checks for the left BKA.

On 11/11/16 the daily wound assessment section documented no wounds, no wound interventions or assessments. This section of the nursing flowsheet had no nurse signature or initials.

On 11/12/16 the daily wound assessment section documented no wounds, no wound interventions or assessments. This section of the nursing flowsheet only had one nurse signature listed.

On 11/13/16 the daily wound assessment section documented three wounds loaded at: right ankle, buttocks and left BKA. The only times interventions were documented for these three wounds was on the night shift. No documentation was listed under the interventions for dayshift.

On 11/16/16 at 9:05 AM, EI # 1, Director of Operations and EI # 3, Director of Clinical Services, confirmed the above information and noted nursing staff were to document on the daily wound assessment section if patients have a wound.

Based on review of medical records, facility policy and interviews, it was determined the facility failed to ensure each patient's Plan of Care (POC) was complete and up to date to meet the patients needs.

This affected 3 of 6 medical records reviewed, including Patient Identifier (PI) # 1, PI # 5, PI # 6 and has the potential to negatively affect all patients served by the facility.

Findings include:

Facility Policy: Interdisciplinary Team Conference

Guideline:

The Interdisciplinary Team Conference is held every week. Each discipline will plan the projected type of care needed and expected goals on each patient. Progress toward set goals will be monitored and reviewed...

Individualized patient interdisciplinary plans and goals are discussed based on the patient's diagnoses, reason for admission, acute problems, needs, strengths, and acceptable discharge placement. The plans and goals are written, reviewed, and revised weekly with goals and interventions which staff will employ to assist the patient in obtaining his/her goals by projected discharge...

Procedure:
1. Prior to team conference, each discipline (with exception of the physician) will complete a team conference report sheet for each patient under treatment. In addition to the discipline specific report sheet information, each discipline will identify long and short-term goals for each patient and document the patient's progress toward the previous goals.

2. Each discipline specific team conference report sheet will be kept together and a notation regarding the estimated length of stay and the discharge destination will be written by the internal care manager. Team Conference documents will be maintained as part of the patient's permanent medical record...

Nurses
Responsible for assessing the patient's needs, planning for, implementing and evaluating the nursing care of each patient to include patient/family education and needs.

Responsible for organizing, administering, and supervising the implementation of a written nursing care plan for each patient...


1. PI # 1 was admitted to the facility on 10/27/16 with diagnoses including Metabolic Acidosis, Acute Aphasia and Encephalopathy.

Review of the Admission Orders dated 10/27/16 revealed the patient was to have nothing by mouth and was to receive Nepro tube feedings at 20 milliliters (ml)/hour (hr) with a goal of 40 ml/hr.

Review of the Nurse's 24 Hour Assessment & Progress Record dated 10/28/16 at 7:40 AM revealed the nurse documented patient had a wound located on the right thigh with a dressing that was clean, dry, intact and a wound to the sacral area and the WCN (wound care nurse) was notified.

Review of the Nurse's 24 Hour Assessment & Progress Record dated on 10/28/16 at 2:00 PM, the nurse documented the wound care nurse was at bedside and applied wound VAC (Vacuum assisted closure) device.

Review of the Physician's Order dated 10/28/16 at 2:55 PM revealed the following wound care orders:

Sacral wound - apply skin prep and place Mepilex border over the wound bed to the sacral wound and to apply Lantiseptic to the patient's buttocks twice a day and PRN (as needed)

Right inner thigh - cleanse the wound with NS (Normal Saline), apply skin prep to the periwound area, fill the wound bed with black foam and apply suction at 125 mmHg (millimeters/Mercury) to be changed on Monday, Wednesday and Friday.

Review of the WCN documentation signed and dated 10/31/16 at 3:52 PM by the nurse revealed the patient had wounds to the right thigh, bilateral buttocks and bilateral heels.

Review of the Physician's Order dated 10/31/16 at 3:55 PM, revealed orders to apply skin prep to bilateral heels, apply Tegaderm foam adhesive dressings to be changed every three days and PRN.

Review of the Interdisciplinary Team Conference Plan of Care dated 10/31/16 revealed no documentation of the patient's impaired skin integrity or nutritional status and tube feedings.

An interview was conducted on 11/16/16 at 8:50 AM with Employee Identifier (EI) # 3, Director of Clinical Services, who verified the above findings.

2. PI # 5 was admitted to the hospital on 11/7/16 with diagnosis of Acute Respiratory and Renal Failure. A review of the wound care nurse documentation dated 11/8/16 documented the following: Wound number 1: Location: Buttocks - bilateralWound type: PressureWound stage: IIWound size: (L) 5.0, (W) 10.0, (D) 0.0
Current treatment for this wound was documented as: Lantiseptic to buttocks and perineum twice a day and as needed. Turn patient every two hours. Wound number 2:Location: Buttocks - bilateralWound type: other - excoriationWound degree: partial thicknessCurrent treatment for this wound was documented as: Lantiseptic to buttocks and perineum twice a day and as needed. Turn patient every two hours. A review of the nutrition care assessment dated 11/8/16 documented PI # 5 was on a pureed diet. The nutrition diagnostic statement documented PI # 5 was at nutritional risk second to her diagnosis and past medical history. The goal listed was to provide adequate calories and protein to promote optimal nutritional status. The plan documented the Registered Dietitian would follow up on PI # 5's appetite and intake and would order a supplement if intake was "suboptimal." There was no mention of PI #5's skin breakdown on the nutritional assessment. A review of the Interdisciplinary Team Conference Plan of Care (care plan) dated 11/7/16 had no updates or documentation related to PI # 5 being placed in restraints, having skin impairment issues or nutritional risks. On 11/16/16 at 7:45 AM, in an interview with Employee Identifier (EI) # 3, Director of Clinical Services, the above information was confirmed and there was no documentation related to skin or nutrition on PI # 5 care plan.

3. PI # 6 was admitted to the hospital on 11/4/16 with diagnosis of Congestive Heart Failure, Acute Chronic Renal Failure, Diabetes, and left Below the Knee Amputation (BKA).

A review of the physician orders dated 11/7/16 at 4:40 PM and 5:05 PM, revealed the following wound care orders:

4:40 PM:
Cleanse left knee and right foot with normal saline. Cover with Xeroform gauze (A sterile, fine mesh gauze impregnated with a blend of 3% Bismuth Tribromophenate (Xeroform) and USP Petrolatum. (www.deroyal.com)

5:05 PM:
Cleanse right ankle wound with normal saline. Cover with a Mepilex border. Change the dressing daily.
Lantiseptic to buttock, thighs and inguinal folds with a day at 9:00 AM and 9:00 PM.
Resinol to buttocks, thigh and inguinal folds twice a day at 2:00 AM and 2:00 PM.
Turn patient from right to left every 2 hours - do not allow patient to lie flat on (his/her) back.
Right heel protector at all times - float heel and foot.

When the medical record for PI # 6 was reviewed there were no care plans in the chart. Hospital staff were asked for a copy of the care plans for PI # 6 and one was provided on 11/16/16. A review of the Interdisciplinary Team Conference Plan of Care (care plan) showed a date of 11/14/16. There was no documentation on the care plan related to PI # 6's skin impairment.

Based on review of facility policies, observations and interviews with facility staff, it was determined the nurse failed to prepare and administer medications according to the facility's policies.

This affected 2 of 6 medical records reviewed, including Patient Identifier (PI ) # 5, PI # 6 and observations of medication administration for two unsampled patients, PI # 7, PI # 8. These deficient practices also have the potential to negatively affect all patients admitted to this facility.

Findings include:

Facility Policy:
Hand Hygiene

I. Policy: Hand washing is considered to be the single most important procedure in the prevention of the spread of infections. All personnel will wash their hands according to this procedure.

II. Procedure

A. Healthcare personnel handwashing and hand antisepsis

2. Hands must be care for by handwashing with soap and water or by hand antisepsis with alcohol-based hand rub (if hands are not visibly soiled):

a. Before and after patient contact...

c. After removing gloves...

C. Other aspects of hand care and protection.

1. Glove use

a. Gloves should be used as a adjunct to, not a substitute for, handwashing.

b. Gloves should be used for hand-contaminating activities. Gloves should be removed and hands washed when such activity is completed...

Facility Policy:
USP (United States Pharmacopeia) 797 Sterile Admixture

Guideline:
Compounding personnel are responsible for ensuring that Compounded Sterile Preparations (CSPs) are accurately identified, measured, diluted, and mixed and are correctly purified, sterilized, packaged, labeled, stored, dispensed, and distributed.

These performance responsibilities include maintaining appropriate cleanliness conditions and providing labeling and supplementary instructions for the proper clinical administration of CSPs...

Procedure:

H. Preparing IV (intravenous) Solutions Outside of Barrier Isolator

1. The intravenous solution must be prepared as prescribed, without microbial or particulate contamination, be unaltered by incompatibilities of interacting agents...

2. If a patient requires an IV solution in an emergency situation and/or access to a barrier isolator is not available, the solution may be compounded outside of a barrier isolator, using the following guidelines:

... B. Clean the work surface with a non-lint producing gauze pad using isopropyl alcohol...

F. Prepare the admixture using aseptic technique by:

b. Wiping stoppers on vials or entry ports on bags with an alcohol swab prior to needle entry. Wipe in one direction. Let the alcohol dry...


Facility Policy: Medication Administration and Medication Administration Records (MAR)
Policy #: 20-06044

I. Guideline

To ensure complete and accurate records of drug administration, Nursing, Respiratory Therapy and Pharmacy Services will maintain a Medication Administration Record (MAR) for inpatients...

... A daily MAR will be generated electronically for every inpatient by the Pharmacy and delivered to the nursing unit before midnight. A nurse will be responsible for comparing the new MAR to the previous day MAR and verify its correctness...

... The licensed nurse must check all ordered transcribed on a MAR by a Unit Secretary including the name, dose, frequency, route, any specific administration instructions and the administration... The licensed nurse must check the new MAR against the old previous day MAR for accuracy and initial each item on the MAR indicating that the MAR has been verified...

II. Procedure

A. New Order

The RN (Registered Nurse)/ LPN (Licensed Practical Nurse)/ Unit Secretary:

1. Documents all new medication orders... in a blank square of a pre-printed MAR on either a scheduled meds (mediations) page or the PRN (as needed) meds page as indicated...

1. PI # 5 was admitted to the hospital on 11/07/16 with diagnosis of Acute Respiratory and Renal Failure. A review of the Medication Administration Record (MAR) dated 11/7/16 to 11/8/16 revealed nursing staff failed to document PI # 5's Peripherally Inserted Central Catheter (PICC) was flushed at 10:00 PM. The MAR dated 11/11/16 to 11/12/16 revealed no documentation nursing staff performed a blood glucose check at 9:00 PM as ordered by the physician. In an interview on 11/16/16 at 7:45 AM, Employee Identifier (EI) # 3, Director of Clinical Services, confirmed the above findings.

2. PI # 6 was admitted to the hospital on 11/04/16 with diagnosis of Congestive Heart Failure, Acute Chronic Renal Failure, Diabetes, and left Below the Knee Amputation.

A review of the MAR revealed the nursing staff failed to administer:

On 11/5/16 to 11/6/16: Lovenox 30 milligrams at 6:00 PM.

On 11/11/16 to 11/12/16: the blood glucose results at 9:00 PM.

On 11/5/16 at 4:40 PM, it was documented PI # 6 was given 7.5 milligrams of Percocet for a pain rating of 8. There was no other pain assessment documented for the remainder of this 24 hour period.

In an interview on 11/16/16 at 9:05 AM, EI # 1, Director of Operations, confirmed the above findings.

Observations of medication administration:

An observation of medication administration for PI # 7 was conducted on 11/15/16 at 8:15 AM with EI # 6, Registered Nurse (RN). During this observation, EI # 6 removed the lid of the IV medication vial and failed to clean the stopper of the vial with alcohol prior to drawing up the medication into a syringe and administering it to PI # 7. After administration of the IV medication, EI # 6 failed to clean the Hep-lock injection port with alcohol prior to flushing it with Sodium Chloride (NaCl). EI # 6 removed gloves and failed to perform hand hygiene after glove removal.

EI # 6 then prepared medications for PI # 8. Observation of medication administration for PI # 8 was conducted on 11/15/16 at 8:38 AM. PI # 8 was on contact isolation. EI # 6 failed to perform hand hygiene prior to donning gloves before entered the patient's room. EI # 6 removed the lid of the IV medication vial and failed to clean the stopper of the vial with alcohol prior to drawing up the medication into a syringe and administering it to PI # 8.

An interview was conducted on 11/16/16 at 10:15 AM with EI # 2, Director of Pharmacy, who verified the staff are to wipe the stopper of each vial once with an alcohol wipe and allow it to dry before drawing up a medication from the vial.

Based on review of medical records and interviews with facility staff, it was determined the medical records were not complete, dated and timed for 4 of 6 medical records reviewed. This affected Patient Identifier (PI) # 1, PI # 2, PI # 3 and PI # 4.

Findings include:

1. PI # 1 was admitted to the facility on 10/27/16 with diagnoses including Metabolic Acidosis, Acute Aphasia and Encephalopathy.

Review of the Physical Therapy Daily Notes signed by the Licensed Physical Therapy Assistant (LPTA) on 11/5/16 revealed no documentation of times. The documentation included, " Pt (patient) in dialysis throughout time LPTA was in hospital..."

Review of the Treatment Administration Record (TAR) revealed this document began on Sunday and ended on Saturday. This document had the date on 10/29 for Friday. In the box for Friday 10/29, there was the entry "WCN (wound care nurse)" There was no documentation of time. There was no documentation of the date for Saturday, nor was there documentation of the times treatments were completed.

Review of the TAR for the week of Sun (Sunday) "30th" to Sat (Saturday)Nov (November) 5th revealed no documentation of the dates for each entry, nor was there documentation of all times in which treatments had been completed only initials and shifts.

Review of the TAR for the week of Sun 11/6 to Sat 11/12 revealed no documentation of all times in which treatments had been completed only initials and shifts.

An interview was conducted on 11/16/16 at 8:50 AM with Employee Identifier (EI) # 3, Director of Clinical Services, who verified the TAR was not completely documented with dates and times.

2. PI # 2 was admitted to the facility on 10/25/16.

Review of the Treatment Administration Record (TAR) revealed this document began on Sunday and ended on Saturday, which was undated.

Review of the TAR for the week of Tue (Tuesday) "10/25" to Sat revealed no documentation of the dates for each entry, nor was there documentation of all times in which treatments had been completed only initials and shifts.

Review of the TAR for the week of Thur (Thursday) "10/27" to Sat "10/29" revealed no documentation on 10/29/16 of the time the nurse documented the dressing to the abdomen was "intact" with initials.

An interview was conducted on 11/16/16 at 8:20 AM with EI # 3, who verified the above findings.



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3. PI # 3 was admitted to the facility on 11/7/16 with diagnoses including Small Bowel Obstruction with Resection on 11/1/16.

Review of a TAR in the record revealed treatment orders for the buttocks and for an abdominal wound. There were entries made on the form with no date/time documented. There was one date (11/10/16) entered in the Thursday column.

Further review of the MR revealed a TAR for the week of 11/13/16 - 11/19/16 with entries made for Monday and Tuesday with no date identified.

An interview conducted on 11/16/16 at 10:30 AM with EI # 1, Director of Operations, confirmed the above findings.

4. PI # 4 was admitted to the facility on 10/27/16 with diagnoses including Right Arm Cellulitis, Respiratory Failure and Open Abdominal Wound.

Review of the MR revealed a TAR for a seven day period with treatment entries documented and no date on the form. Entries were made by 5 different nurses.

An interview conducted on 11/16/16 at 9:00 AM with EI # 1 confirmed the above findings.

Based on review of facility policies, observations of care and interviews with facility staff, it was determined the facility failed to ensure staff:

1) Performed hand hygiene prior to medication preparation, before and after donning gloves.

2) Turned the sink faucet off using a paper towel after washing hands.

3) Maintained sterile procedure while completing a straight catheterization of a patient.

4) Wore personal protective equipment (gowns) appropriately for patients who were on contact isolation precautions.

5) Cleaned point of care device (Glucometer) immediately after use for a patient on contact isolation and placed the meter on the nursing station counter top prior to cleaning it with approved cleaner, thus potentially contaminating the counter top.

These deficient practices have the potential to negatively affect all patients admitted to this facility.

Findings include:

Facility Policy:
Hand Hygiene

I. Policy: Hand washing is considered to be the single most important procedure in the prevention of the spread of infections. All personnel will wash their hands according to this procedure.

II. Procedure

A. Healthcare personnel handwashing and hand antisepsis

2. Hands must be care for by handwashing with soap and water or by hand antisepsis with alcohol-based hand rub (if hands are not visibly soiled):

a. Before and after patient contact.

b. After contact with a source of microorganisms (body fluids and substances, mucous membranes, non-intact skin, inanimate objects that are likely to be contaminated).

c. After removing gloves...

C. Other aspects of hand care and protection.

1. Glove use

a. Gloves should be used as a adjunct to, not a substitute for, handwashing.

b. Gloves should be used for hand-contaminating activities. Gloves should be removed and hands washed when such activity is completed...

Facility Policy:

Catheterization, Urinary; Indwelling and Condom

... IV. Straight Catheterization Procedure

... C. Procedure for Males

RN/LPN (Registered Nurse/Licensed Practical Nurse):

1. Assists patient to supine position...

2. Washes Hands...

4. Opens sterile wrapping of catheter kit:
a. Uses strict aseptic technique to put on sterile gloves...

Facilty Policy:
Isolation Precautions

Guidelines on Initiation of Isolation

I. Purpose: Initiation of isolation guidelines is designed to outline the process used to admit an infectious patient to the Hospital and/or initiate isolation after admission when a multi-drug resistant organism is identified in an existing patient...

Contact Isolation
Purpose: Designed to prevent transmission of known or suspected serious illnesses (or colonization) easily transmitted by direct patient contact or by contact with items in the patient's environment.

*Note: All diseases or conditions in the category are spread by direct contact...

Specification for Contact Isolation:

... 3. Gowns are indicated if soiling is likely.

4. Gloves are indicated for touching infective material.

5. Hands will be washed before taking care of another patient...

Facility Policy: POC (Point of Care) Testing by Glucometer: Blood Sample Collection...

I. Guideline
... NOTE: Follow all facility safety and infection control policies when collecting blood samples...

II. Fingerstick Sample Collection

... 2. Wash hand and don gloves and any other personal protective equipment as required by infection control and isolation policies and procedures.

3. Follow all facility infection control protocols when testing isolation patients...

... 13. Discard lancet... and all sample collection and testing materials...

15. Clean and disinfect the meter...

Facility Policy:
Cleaning, Sterilization, High-level Disinfection and Storage of Patient Care Devices and Other Items

Purpose: To provide clean and sterile supplies for patient care. To define the responsibility for cleaning, disinfecting, sterilization and storage of patient care instruments and other patient care items...

I. Classification of Patient Care Items

... C. Non-critical Items

Medical devices that come in contact with intact skin, but not mucous membranes only need cleaning or low-level disinfection...

The following agents will be acceptable for disinfection provided that the manufacturer's recommendations are followed:
Ethyl or isopropyl alcohol (70-90%)...

An observation of wound care provided to PI # 3 on 11/14/16 at 12:30 PM by EI # 9, Registered Nurse (RN) Wound Care Nurse, revealed the RN failed to follow policy for hand hygiene. The RN was observed removing gloves and donning clean gloves 3 times during the procedure without performing hand hygiene in between gloves changes.

An observation of medication administration to PI # 7 was conducted on 11/14/16 at 1:00 PM with Employee Identifier (EI) # 6, Registered Nurse (RN). EI # 6 donned gloves, administered the subcutaneous (sq) medication. EI # 6 failed to perform hand hygiene prior to administration of the sq medication and after glove removal.

An observation of medication administration for PI # 7 was conducted on 11/15/16 at 8:15 AM with EI # 6, RN. After EI # 6 administered the patient's medications, she removed gloves and failed to perform hand hygiene after glove removal.

EI # 6 then prepared the medications for PI # 8. Observation of medication administration for PI # 8 was conducted on 11/15/16 at 8:38 AM. PI # 8 was on contact isolation. EI # 6 failed to perform hand hygiene prior to donning gloves before entered the patient's room. EI # 6 failed to tie the personal protective equipment (gown) completely prior to entering the patient's room, thus the strings were dragging on the floor the entire time EI # 6 was in the patient's room. After the Intravenous (IV) medication was administered, EI # 6 reached into the pocket of her lab coat, which was under the gown with her gloved hand and obtained a syringe of NaCl (Sodium Chloride) to flush the patient's Hep-lock, thus contaminating her lab coat.

On 11/15/16 at 9:00 AM, the surveyor observed EI # 7, Patient Care Technician perform capillary blood glucose testing on PI # 9, who was on contact isolation. EI # 7 completed testing with the Accu-check meter, placed it on the chair in the patient's room, removed her gloves/gown, then picked up the Accu-check meter and exited the patient's room. EI # 7 placed the Accu-check meter on top of the isolation supply cart, documented the patient's blood sugar results, then took the Accu-check meter to the nurses station. EI # 7 placed the contaminated Accu-check meter on the counter top at the nurses station, thus contaminating the counter top of the nurses station. EI # 7 then cleaned it with 70% alcohol pad.



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An observation was completed on 11/15/16 at 10:25 AM with EI # 8, RN, and an unsampled patient that required a straight catheterization to drain the bladder. EI # 8 was observed performing hand washing in the patient's bathroom and failed to use a paper towel to turn off the water resulting in contamination of her clean hands. EI # 8 donned non-sterile gloves and prepared the patient for the procedure. EI # 8 removed the gloves and opened and donned sterile gloves without performing hand hygiene. EI # 8 then picked up the straight catheter using both hands and peeled back the outer wrap of the catheter thus contaminating the sterile gloves. EI # 8 completed the procedure, discarded all used supplies and gloves, regloved without performing hand hygiene and emptied the urinal. EI # 8 discarded those gloves and washed her hands in the patient's bathroom and failed to use a paper towel to turn off the water thus contaminating her clean hands.

On 11/15/16 at 12:20 PM, the surveyor observed EI # 10, Dialysis RN was in the room of a patient who was on contact isolation. EI # 10 failed to have her gown secured around her waist and the ties were dragging the ground in the patient's room. On 11/15/16 at 1:35 PM, EI # 10 was preparing to re-enter the room of the patient who was on contact isolation, EI # 10 pulled the strings off the front of the gown, which left a hole in the front of the gown, then entered the patient's room.

During end of day discussion conducted on 11/15/16 at 4:15 PM with EI # 1, Director of Operations and EI # 4, Administrator, they verified the staff failed to follow infection control procedures.

Based on review of medical records (MR) and interview with the staff it was determined the staff failed to provide and document Incentive Spirometry treatments as ordered for 1 of 1 record reviewed of a patient with physician orders for Incentive Spirometry treatments, including Patient Identifier (PI) # 3 and had the potential to affect all patients admitted to the facility.

Findings include:

1. PI # 3 was admitted to the facility on 11/7/16 with diagnoses including Small Bowel Obstruction with Resection on 11/1/16.

Review of the MR revealed a physician's order dated 11/9/16 at 4:45 PM for Incentive Spirometry Q (every) 2 hrs (hours) while awake.

Review of the MR revealed no documentation the Incentive Spirometry was provided.

An interview conducted on 11/16/16 at 10:30 AM with Employee Identifier # 1, Director of Operations, confirmed there was no documentation the ordered treatments were provided.