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Based on interview and record review, the facility failed to meet the Condition of Participation for Nursing Services by failing to develop a comprehensive care plan that addressed Intravenous (IV) access care for 2 (#1 and #3) of 2 patients and failed to assess/document wound care treatments for 3 (#'s 1, 3 and 4) out of a total of 5 sampled patients, resulting in the potential for poor outcomes for all patients with IV access and or open wounds served by the facility. Findings include:


---(See A 396) The facility failed to develop (IV) plans of care for 2 (#1 and #3) of 4 patients out of a total sample of 5 and the facility failed to document daily wound care treatments for 3 (#'s 1, 3 and 4) of 4 patients.

Based on interview and record review, the facility failed to develop and maintain an active hospital wide Infection Control Program for the prevention, control and investigation of infections. Resulting in the increased potential for increased risks of infections for all patients treated in the facility.

See specific A tag:

A-0748. Failure to ensure staff was designated and qualified for the role of an Infection Control Officer.
A-0749- Failure to monitor and consistently conduct active surveillance activities.

Based on interview and record review the facility failed to ensure 1) nursing staff developed a care plan that addressed Intravenous (IV) access for 2 patients (#1 and #3) and 2) the facility failed to ensure nursing staff documented wound care treatments were performed according to the plan of care and medical doctor orders for 3 of 3 patients (#'s 1, 2 and 4) out of a total of 5 sampled patients reviewed for care plans, resulting in the potential for less than optimal outcomes for all patient's with IV access and open wounds served by the facility. Findings include:

Patient #1

On 5/16/17 at 1500 patient #1 was observed in her room while accompanied by Registered Nurse (RN) Staff E.

Staff E was asked if the patient (#1) had a intravenous access (IV) and/or open wounds. Staff E was observed as she looked for the date on the patient's right upper arm (IV) dressing. Staff E stated, "I can't read the date. It's not legible."

On 5/16/17 at 1515 a review of the medical record for patient #1 was conducted with the Chief Clinical Officer Staff (C). Patient #1 was an 69 year old female that was admitted to the facility on 4/20/2017 with diagnoses that included sepsis and pressure sores.

A review of the patient's care plans revealed there were no Care plans that addressed the patient's IV access. Further review of the patient's medical record documented the patient's IV access dressing was last changed on 5/3/17 (13 days). Additionally, there were physician's orders dated 4/20/17 through current (5/16/17) for daily wound care for patient #1's wounds. However, wound care was not documented as performed on 4/27/17.

At that time Staff C said, the nursing staff should have written a legible date on the patient's IV dressing. When further queried Staff C offered no further explanation regarding the lack of a Care plan for the patient's IV access or why the patient's wound care was not performed on 4/27/17.

Patient #3

On 05/16/17 at approximately 1230, while accompanied by Licensed Practical Nurse (LPN) Staff F, patient #3 was observed in bed. Staff F was asked if the patient had a intravenous access (IV) and/or open wounds. Staff F was observed as she looked for the date on the patient's right mid-arm (IV) dressing. Staff F stated, "It's (IV) not dated." She said the IV should have been dated when the IV dressing was changed.

On 5/16/17 at 1300 a review of the medical record for patient #3 was conducted with the Chief Clinical Officer Staff (C). Patient #3 was an 85 year old male that was admitted to the facility on 2/23/2017. The patient's diagnoses included sepsis and multiple open wounds. A review of the patient's care plans revealed there were no Care plans that addressed the patient's IV access. Further review of the patient's medical record revealed the patient's IV access dressing was not changed between 4/17/17 and 5/10/17.

Additionally, further review of the medical record revealed physician's orders dated 2/23/17 through current (5/16/17), for daily wound care for patient #3's wounds. However, wound care was not documented as performed on the following dates:
On 3/1, 3/5, 3/8, 3/10, 3/13, 3/26, 3/30, 3/31, 4/1, 4/2, 4/10, 4/15, 4/25, 4/26, 4/27, 4/30, 5/3, 5/5, 5/13 and 5/14/17. At that time Staff C offered no further explanation when asked to explain why the patient's wound care was not documented as performed or why there was no IV care plan developed in the patient's medical record.

Patient #4

On 5/17/17 at approximately 1400 a review of patient #4's medical record was conducted with the Director of Quality Management Staff (B). Patient #4 was admitted to the facility on 2/8/17 with diagnoses that included respiratory failure. Review of the wound care assessment dated 2/9/17 documented the patient had a skin abrasion to his mid-back there were no measurements documented on the nurses assessment.

Physician orders for patient #4 dated 2/11/17 documented the patient's skin abrasion was to be cleaned daily. An antibiotic ointment was to be applied, and the wound was to be secured with a border gauze dressing daily. However, wound care was not documented as performed on the following dates:
2/10, 2/13, 2/14, 2/15, 2/16, 2/18, 2/19, 2/21, 2/22, 2/24, 2/25, 2/26, 2/28, 3/1, 3/3, 3/4, 3/11, 3/12, 3/13, 3/14, 3/15, 3/16, 3/17, 3/18, 3/19, 3/21, 3/22, 3/23, 3/24, 3/25, and 3/26/17.

At that time Staff B confirmed there was no further evidence that documented patient #4's daily wound care had been performed on the aforementioned dates.

On 5/17/17 at 1030 a review of the facility's "Peripheral IV Site Care and Dressing Change" policy H-PC 05-009, dated 10/2016, documented:
Procedure: #2. Transparent semipermeable membrane dressing will be changed every 5-7 days and/or as soon as possible after discovery, when the integrity of the dressing is compromised; if moisture, drainage, or blood is present; or if further assessment if site infection of inflammation is suspected.

A review of the facility's "Assessment/Re-Assessment-Interdisciplinary Patient" policy H-PC-02-001 PRO, dated 06/2016, documented: Procedure: 3. Nursing Department...C. The admission assessment data is a primary source for the RN to determine and prioritize nursing care needs specific to the patient. A Patient Plan of Care developed and recorded within 24 hours of admission by the RN based on identified problems and patient specific needs.

Based on interview and record review, the facility failed to follow their policy to ensure that a qualified Infection Preventionist was designated for the role of the infection control preventionist, had received specialized training in infection control and performed consistent surveillance activities, resulting in the increased potential for unidentified infections and/or the increased potential for the transmission of infections for all patient's in the facility. Findings include:

On 05/17/17 at approximately 1100, an interview and review of the infection control program was conducted with the Director of Quality Management Staff B. Staff B explained she, the Chief Nursing Officer (Staff C) and the Staff Educator (Staff I) were responsible for the Infection Control program. Staff B stated "We have a nurse who helps us out. He (Staff D) used to be our Infection Control Preventionist. He works as needed. When asked to provide evidence that the aforementioned staff members were trained and or certified for the role of the Infection Preventionist, Staff B stated, "None of us are certified. None of us have any special training."

On 5/17/17 at 1400 a review of Staff D's personnel file was conducted with Staff B. There was no evidence that documented Staff D was or had been qualified for the position for Infection Control Preventionist.

On 5/17/17 at approximately 1515 Staff C stated, "Staff D no longer works here."

On 5/17/17 at 1430 a review of the facility's "2017 Annual Infection Prevention and Control Plan", dated 2/28/17 documented the following:
Infection Prevention and Control Program:
"...The team consists of the Infection Preventionist, Director of Pharmacy, Chief Clinical Officer, Directory of Quality Management,...and ad hoc members as deemed necessary...The Infection Preventionist maintains competency by continuous education through the national APIC Chapter, seminars or classes that relate to the profession, and Certification in Infection Control (CIC)...".

Based on observation, interview and record review, the facility failed to 1) ensure staff identified and/or maintained isolation precautions for 2 (#3 and #5) of 5 patient's reviewed for infection control out of 5 sampled patients and 2) the facility failed to ensure staff conducted surveillance activities and consistently analyzed surveillance findings, resulting in the potential for the spread of infections for all 35 patients served by the facility. Findings include:

On 5/16/17 at approximately 1130 during a tour of the facility while accompanied by the Clinical Chief Officer (Staff C) isolation carts containing personal protective equipment (PPE) were observed in the hallways near patient rooms on the 2nd and 3rd floor nursing units.

When queried regarding if the isolation carts were just stored on the units or if the patient's were in isolation, Staff C said the carts were in use for current patient's in isolation and they were stored on the units in the event they were required for a patient requiring isolation precautions. Staff C explained if the patient were in isolation a sign would be posted on the patient's door identifying the type of precautions.

At that time an isolation sign and an isolation cart were observed posted at room for patient #5. A staff member was observed in the room near the patient's bed. The staff member was not wearing (PPE). Staff C was asked if the patient was in isolation. Staff C explained the patient's was receiving therapy. Staff C was overheard as he asked rehabilitation Staff L who was in the room with the patient (#5), if the patient was in isolation. Staff L was observed they shook their head left to right (no).

On 05/16/17 at approximately 1230, while accompanied by Licensed Practical Nurse (LPN) Staff F, patient #3 was observed in bed. A isolation cart was observed near the door entry. There was no sign posted on the patient's door. Staff F was asked if the patient had a intravenous access (IV) and/or open wounds. Staff F confirmed the patient had an IV. She explained she had already performed wound care for the patient. Staff F was observed as she entered the patient's room without donning PPE. Staff F was observed as she donned a pair of gloves after she entered the patient's room. Staff F proceeded with lifting the top covers off of the patient to show the surveyor the patient's IV access and the patient's right hip wound dressing. Staff F explained that there was no date on the patient's IV dressing. She said the IV should have been dated when the IV dressing was changed.

On 5/16/17 at 1300 a review of the medical record for patient #3 was conducted with the Chief Clinical Officer Staff (C). Patient #3 was an 85 year old male that was admitted to the facility on 2/23/2017 with diagnoses that included sepsis. Further review of the medical record revealed the patient had multiple open unstageable wounds to his sacrum and bilateral lower extremity's and was on IV antibiotics for an infection.

On 5/17/17 at 1100 a review of the infection program was conducted with the Director of Quality Management (Staff B). Staff B was asked to provide evidence that documented surveillance activities including the patient and staff environment involving patient care, environmental services, dietary services, house surveillance, employee health data etc, were performed consistently, recorded and reported accordingly to acceptable standards. Staff B explained she could not provide committee minutes that demonstrated the aforementioned concerns were conducted and analyzed routinely.

Staff B provided the following 3 infection control surveillance audits:
On 2/28/17, the 3rd floor SW nursing unit was audited.
On 3/17/17, the 3rd floor SW nursing unit was audited.
On 4/3/17, the 2nd floor nursing unit was audited.

However, the forms did not identify the time of the observations or the staff members who failed to comply with the facilities infection control policy/procedures.
There were no audits conducted for hand hygiene compliance. Staff B explained that staff were watched all the time. However, Staff B was unable to provide further evidence that documented staff were monitored for hand hygiene expect on the aforementioned dates.

When asked to explain why there were no audits conducted for dietary services, Staff B stated, "I know they document refrigerator temperatures. They don't record any other audits. They don't prepare food here."

Further review of the Infection Program revealed a surveillance log (dated 5/2017) that the documented patient #3 was on Isolation Precautions. She (Staff B) explained the patient had multiple wounds and was recently started on IV antibiotics (Meropenem) 500 milligrams (mg) every 8 hours on 5/14/17. However, Staff B was unable to provide evidence that documented the source of the patient's infection.

Further review of the Infection Control Program documented patient #5 was admitted to the facility on 5/3/17. Contact precautions were recorded on the surveillance log. However, the log did not document the location of the patient's infection. Staff B stated, "The patient is on Contact Isolation Precautions". She explained that she was responsible for updating the log and confirmed the log was incomplete. Additionally, Staff B was unable to explain why facility staff (C and L) were not able to verbalize if the patient's (#'s 3 and 5) were on Isolation Precautions.

On 5/17/17 at 1430 a review of the facility's "2017 Annual Infection Prevention and Control Plan", dated 2/28/17 documented the following:
Infection Prevention and Control Program:
"...The team consists of the Infection Preventionist, Director of Pharmacy, Chief Clinical Officer, Directory of Quality Management,...and ad hoc members as deemed necessary...The Infection Preventionist maintains competency by continuous education through the national APIC Chapter, seminars or classes that relate to the profession, and Certification in Infection Control (CIC)...".