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Based on review of Medical Records (MR), facility policy, physician orders, and interviews with staff it was determined the facility failed to ensure:

1. Diabetic teaching was performed to include sliding scale insulin use, signs of hypoglycemia or hyperglycemia, or use of glucometer for home glucose monitoring.

2. The physician was notified of elevated Blood Glucose readings.

3. The nurses documented the location and description of bruising.

4. Physician orders were followed for removing surgical staples and wound dressing changes.

5. The Insulin was given as ordered per sliding scale.

6. The physician was notified of a worsening wound condition.

7. The physician was notified of bowel movements greater then 3 days.

This deficient practice affected 3 of 4 MR's reviewed and did affect Patient Identifier (PI) # 4, PI # 2 and PI # 3 and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: No policy for Diabetes Care or Management was provided to surveyor upon request.

Policy: Patient and Family Education
Policy # 550
Last reviewed: 8/21/19

...Policy: The patient/family/caregiver will be assessed for educational needs and provided appropriate individual education from all disciplines on the treatment team... The team coordinates the patient education and training provided by all disciplines involved in the patient's care, treatment, and services...

Documentation: The hospital evaluates the patient's understanding of the education training provided. Documentation of the patient/family/caregiver education plan include:

1. Assessments that identify the patients individual needs

2. Interdisciplinary Team Conference Form

3. Progress Notes

4. Flowsheets

5. Discharge Documentation

Family members/caregivers will be provided opportunities for formal or informal teaching sessions and individual family conferences with the clinicians and receive instruction about the care and treatment recommendations...

Policy: Wound Assessment and Documentation
Policy # 2
Last Reviewed Date: 8/21/19

Purpose:

1. To improve patients' skin integrity through timely and consistent clinical practices for assessment and prevention of wounds.

2. To ensure standard documentation related to the assessment of skin and wounds.

3. To facilitate both accuracy in wound assessment and quality reporting...

Definitions: The term "wound" is used generically to include all types of alterations in skin integrity....

Assessment: An RN (Registered Nurse) will inspect each patient's integument daily and as often as indicated...

3. Skin tears, procedure-related wounds, traumatic wounds, or ... are not staged. These types of alterations in skin integrity should be described, measured, and photographed...

Documentation: A patient history and physical assessment is needed to determine type/cause of wound...

1. Documentation of assessment: The RN will describe the wound precisely.

A. Wound label: Assign a number...to note the existence and location of a wound.

B. Measurements:...Length, Width, and Depth should be recorded in centimeters on admission or discovery, weekly and at discharge...

Policy Adherence and Reporting:

1. The hospital has identified certain circumstances that must be reported through the hospital Electronic Event Reporting System (RL Solutions)...

C. An event report will be completed for procedure-related wounds and other skin alterations that deteriorate or present some clinical concern based on clinical discretion...

Policy: Bowel Training
Review Date: 8/21/2019
Policy # 210

Purpose:

To develop a method of regular evacuation of fecal material from the lower bowel...

It is the responsibility of the Chief Nursing Officer and Director of Therapy Operations to disseminate information and the Nursing and Therapy staff to assure compliance. It is the responsibility of the licensed staff to set up a bowel program for each patient with impaired bowel elimination.

Policy:

2. RN completes an assessment to determine patient's ability to communicate bowel needs and to consider the patient's willingness to comply with the program.

3. The licensed staff and the patient will develop a bowel program in which the nurse may:

H. Engage in ongoing assessment of bowel elimination patterns. The first assessment is done on admit. Re-assessment is done within 3 days of admission, and then every week until a consistent bowel program is established...

I. If the patient exhibits signs and symptoms of impaction (oozing liquid stool, no BM (bowel movement) min several days), notify the physician for further orders.

Policy: Telephone and Verbal Orders
Review Date: 08/21/2019
Policy Number: 690

Purpose:

To provide necessary medical orders in a timely fashion. To assure verbal/telephone orders affecting patient care are documented accurately.

Policy:

Only physicians and nurse practitioners and physician assistants as allowed by state law may give verbal or telephone orders...

Verbal orders are discouraged and use of them should be limited.

2...All (both medication and treatment orders) verbal/telephone orders must be read back and verified verbatim to the practitioner who gave the order.

3. Once confirmed, each verbal/telephone order must be recorded directly in the medical record.

1. PI # 4 was admitted to the Rehabilitation Facility on 1/23/2020 at 5:00 PM with diagnoses including Recurrent Falls, Lower Extremity Weakness, Bradycardia, and Anemia.

Review of the physician order dated 1/23/2020 at 6:31 PM revealed an order for Diabetes education, constant order.

Review of the POC ( Plan of Care) dated 1/23/2020 revealed plans for the patient including: participate in Diabetic classes, verbalize medications, dosage, and routine, verbalize signs/symptoms of hypoglycemia/hyperglycemia, and verbalize interventions of high/low blood sugar.

On 1/23/2020 at 6:32 PM a POC for Diabetes Management was initiated by nursing service and ordered by the physician on 1/24/2020 which included Blood Glucose (fingerstick) before meals and at bedtime.

The Diabetes Protocol was provided to the surveyor on 2/5/2020 at 2:18 PM that included instructions for nurse to call the physician for blood glucose less than 70 or greater than 400.

Review of the Flowsheet Print Request for Blood Glucose Monitoring revealed the following Blood Sugars (BS) greater than 400 mg/dl (milligrams/deciliter):

1. On 1/23/20 at 7:53 PM BS was 425 mg/dl.
2. On 1/24/20 at 12:16 PM the BS was 409 mg/dl.
3. On 1/28/20 at 3:16 PM the BS was 427 mg/dl.

There was no documentation the nurse notified the physician of the BS readings above 400 mg/dl.

Review of the Integumentary Assessment Flowsheet Print Request revealed the nurse documented "bruising" on in 5 assessments including: 1/24/20 at 8:00 PM, 1/25/20 at 8:00 AM, 1/25/20 at 7:25 PM, 1/29/20 at 8:05 PM, and 1/30/20 at 8:23 AM.

Review of the Integumentary Assessments from 1/24/20 to 1/31/20 revealed no documentation of the location or extent of the bruising.

Review of the physician order dated 1/30/2020 at 8:00 PM revealed a sliding scale insulin order that included an order for 10 units of Novolog insulin to be given for BS between 251 mg/dl and 300 mg/dl.

Review of the Flowsheet Print Request for blood glucose monitoring revealed on 1/31/2020 at 12:05 PM the fingerstick BS was 280 mg/dl.

Review of the MR revealed the patient was discharged to home at 3:40 PM on 1/31/2020.

There was no documentation the 10 units of Novolog insulin was given as ordered per sliding scale prior to patient discharge home.

Review of the MR revealed no documentation of specific diabetic teaching for use of the ordered sliding scale for insulin administration, use of a glucometer for home blood sugar monitoring, or signs and symptoms of hypoglycemia or hyperglycemia.

An interview was conducted on 2/5/2020 at 9:45 AM with EI # 2, Chief Nursing Officer (CNO), who confirmed:

1. There was no documentation of diabetic teaching
2. The physician was not notified of the BS readings above 400 mg/dl on the above stated dates
3. There was no documentation of the bruised location or description
4. No insulin was given on 1/31/2020 per sliding scale after the 12:05 PM BS of 251 mg/dl.

2. PI # 2 was admitted to the facility on 1/27/2020 at 4:30 PM and currently an inpatient at time of survey with diagnoses including: Disk Herniation, Stenosis, Compression, Diabetes Mellitus Type 2, and Hypertension.

Review of the physician orders dated 1/27/2020 at 5:11 PM revealed an order for nurses to remove the staples and sutures from the patients's back.

Review of the MR from 1/27/2020 through 2/4/2020 revealed documentation the staples were intact. There was no documentation the staples or sutures were removed.

Review of the Wound Assessment Flowsheet Print Request revealed on 1/31/2020 at 8:30 AM the nurse documented wound drainage from lower back surgical incision "large, odor free, purulent, serosanguineous."

Review of previous wound assessments revealed only scant to large serosanguinous drainage, not purulent.

There was no documentation the physician was notified of the change of drainage to purulent.

An interview was conducted on 2/4/2020 at 1:00 PM with EI # 2 who confirmed the staples were still intact and had not been removed as ordered and there was no documentation the physician was notified of the change in the wound condition.



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3. PI # 3 was admitted to the facility on 12/12/19 with an admitting diagnosis of Cervical Stenosis, C (cervical) 2-3 with Dorsal Cord Compression, S/P (status post) Surgery.

Review of the physician order dated 12/12/19 at 10:00 AM revealed the following order: Leave neck/back incision open to air, Constant order.

Review of the physician orders dated 12/12/19 at 7:24 PM revealed the following order: Neck, Sterile Saline, Dry, Routine, QHS (every night), cleanse, cover with dry dressing.

Further review of the physician orders revealed an order written on 12/12/19 at 7:37 PM as Neck, Sterile Saline, Other, Routine, QHS, cleanse, leave open to air.

Review of the physician orders dated 12/12/19 at 8:00 PM revealed the following order: Neck, Sterile Saline, Dry, Routine, Cleanse, cover with dry dressing.

Review of the nursing documentation dated 12/22/19 at 9:16 PM revealed the nurse documented Cleaned with Sterile Water.

Review of the physician orders with in the MR revealed no documentation of an order for the Sterile Water.

Review of the nursing Intake and Output (I & O) documentation beginning 12/12/19 to 12/21/19 from both the 7 AM and the 7 PM shifts revealed no documentation of the date of the last bowel movement (BM).

Further review of the I & O documentation revealed on 12/22/19 on the 7 PM shift at 1:00 AM the staff documented the date of the last BM as 12/11/19, which was 11 days since PI # 3 had a bowel movement.

Review of the nursing documentation within the MR revealed no documentation the physician was notified and no new orders were received.

Review of the I & O documentation dated 12/23/19 revealed no documentation of the date of the last bowel movement and the patient was discharged at 11:07 AM on
12/23/19.

An interview was conducted on 2/5/2020 at 9:30 AM with EI # 1, Director of Quality Risk and EI # 2 who confirmed there was no order written for the Sterile Water nor was there documentation of the patients last bowel movement throughout the hospital stay. EI # 1 also confirmed the physician should have been notified and documented in the MR of the physician being notified if new orders were received and if the patient had a bowel movement prior to discharge.

Based on observations, facility policy, and interviews it was determined the facility failed to ensure accepted standards of infection control practices were followed.

These deficient practices affected 2 of 2 Unsampled Patient (UP) observations receiving wound care including UP # 1 and UP # 2 and had the potential to affect all patients admitted to this facility.

Findings include:

Policy: Hand Hygiene
Policy #: 170
Date Reviewed: 4/2/2019

...Policy: Every employee will use proper hand hygiene and hand washing technique.

Indications for Handwashing and Hand Antisepsis...

4. Wash hands after removing gloves...

Other Aspects of Hand Hygiene...

4. Change gloves and perform hand hygiene during patient care if moving from a contaminated body site to a clean body site.

1. UP # 1 was admitted to the facility on 1/29/2020 at 11:15 AM with diagnoses including: Sepsis, Bilateral Leg Wounds, Urinary Tract Infection, Pneumonia, and Anemia.

An observation of wound care to bilateral lower legs was conducted on 2/4/2020 at 2:15 PM.

Employee Identifier (EI) # 3, Registered Nurse (RN), performed the primary wound care while EI # 4, RN, assisted with assembling supplies, opening supplies, applying ointment, and discarding waste.

After applying Silvadene ointment to edges and open areas of wound EI # 4 removed gloves and re donned new gloves and continued to pass sterile dressing supplies to EI # 3. EI # 4 failed to perform hand hygiene after removing gloves

An interview was conducted on 2/6/2020 at 1:00 PM with EI # 2, Chief Nursing Officer (CNO), who confirmed that proper infection control practices were not followed.

2. UP # 2 was admitted to the facility on 1/31/2020 at 3:45 PM with diagnoses including: Bacteremia, Diverticulitis, Sepsis, Sarcoidosis, and Anemia.

EI # 5, RN, performed the primary wound care while EI # 4 assisted with assembling supplies, opening supplies, and disposing of wound materials.

EI # 4 was observed on multiple times during wound care of UP # 2 disposing of material in open trash recepticle then using his/her shoe/foot to pack the material into the trash recepticle.

An interview was conducted on 2/6/2020 at 1:00 PM with EI # 2 who confirmed that proper infection control practices were not followed.