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Based on observation, interview and record review the facility failed to ensure (1) nursing staff updated and implemented a plan of care with individualized interventions that addressed changes in skin condition for 1 (#1) of 4 patients reviewed for skin conditions and (2) the facility failed to ensure nursing assistant supervision and nurse assistant competency for agency Staff K, and (3) the facility failed to ensure nursing staff performed Intravenous (IV) flush for 1 (#2) of 2 patients observed during medication pass observation resulting in the potential for less than optimal outcomes.
Findings Include:

See specific tags:
A-392: Failure to ensure staff performed and demonstrated competency with infection control prevention and Intravenous management.
A-0396: Failure to update a nursing care plan that addressed changes in skin condition.
A-0397: Failure to supervise and document nursing supervision for agency orientee nursing assistant Staff K.

Based on observation, interview and record review, the facility failed to ensure nursing staff performed Intravenous line flush for 1 patient (#2) during medication pass observation and (2) the facility failed to ensure 1 (Staff K) of 3 patient care technicians (PCT) observed were trained and performed infection control prevention practices following direct patient care activities for 1(#1) of 1 patient observed during blood glucose fingerstick checks, resulting in the potential for IV access complications for patient #2 and the potential for the transmission of infections for the 9 patients assigned to Staff K.
Findings include:

On 3/7/18 at approximately 0900 patient (#2) was observed for a medication pass observation with Registered Nurse (RN) Staff M. Patient #2 was observed in a Posey (mesh enclosed) bed used as a restraint to prevent patient falls and/or injury. The patient was not responsive to command at that time. The patient was observed with a double-lumen IV access. The patient was receiving an IV solution of total parental nutrition (TPN) and a primary IV solution of dextrose and sodium chloride both via pump. Staff M explained the patient was scheduled to have a swallow exam and as a result her oral medications were on hold. Staff M was observed as she administered the patient's anti-heartburn intravenous medications and as she swabbed the patient's mouth with an antifungal solution.

On 3/7/18 at 0920 Staff M was observed as disconnected the patient from her IV access lines for her patient (#2) to be transported off the floor for her swallow exam. At 0925 the patient was transported off the floor for her swallow exam. Staff M did not flush the patient's lines post disconnection.

On 3/7/18 at 0928 Staff M was asked to explain if patient's were not transported with IV solutions and/or IV pumps and Staff M was asked to explain if it were necessary to flush the patient's IV ports after disconnecting them. At that time Staff M said, no they (patients) usually don't go with IV's running. In response to flushing the patient's IV line after disconnecting Staff M stated, "Yeah. I didn't do that."

On 3/7/18 at 1240 while accompanied by Staff J patient #1 was observed in her room in bed on her back facing the door. A pillow beneath the patient's head was saturated with a large amount of yellow-blood tinged drainage that was pooled from the right side of the patient's mouth down the right side of her lateral neck and right ear. A nasogastric tube was intact to the patient's right nare and was connected to low continuous wall suction. The patient's left nare was observed with a large amount of blood drainage. There was bloody drainage observed pooling from the patient's mouth. The patient did not respond to verbal command. The patient's lips were dry, cracked and covered with black necrotic tissue.

On 3/7/18 at 1245 Staff K was observed as she entered the patient's (#1's) room. Staff K said she was an agency PCT who was called in to work today. Staff K said she arrived at 1030. Staff K said she was assigned 9 patients. Staff K said she needed to perform a fingerstick for the patient's blood sugar. Staff K was observed as she donned a pair of gloves and proceeded with checking the patient's blood sugar. Staff K completed the test and stated the patient's blood sugar was 305. Staff K was observed as she discarded the lancet into a sharp container, returned the blood glucose monitoring device (BGM) back into the case without cleaning it and removed her gloves and exited the patient's room without performing hand hygiene.

On 3/7/18 at 1249 Staff K was observed as she entered the room adjacent to patient #1's room. Staff K was overheard as she asked the patient their name. She (Staff K) explained she was going to check their blood sugar. At that time the surveyor requested Staff K exit the patient's room and speak with the surveyor. Staff K was asked to explain why she did not clean the BGM. Staff K stated, "I was going to clean it in that patient's room." Staff K when prompted said I'll go back and clean it in patient (#1's room). Staff K then returned to patient #1's room. She obtained a bleach wipe and proceeded to wipe down the outer carrying case for the BGM device. Staff K had to be prompted by the surveyor to clean the actual device. Staff K was overheard as she stated, "No one ever told me to clean the thing." Staff K was then observed leaving the patient's room without performing hand hygiene.

On 3/7/18 at 1255 the Chief Nursing Officer Staff C was observed as she entered the room. Staff C was overheard as she asked Staff K "who are you". Staff K was not wearing a badge. Staff K was wearing burgundy scrubs with a college logo. Staff K explained she was an agency PCT who had worked 4 hours previously on Saturday 3/3/18 for orientation. Staff K was overheard as she explained that she had completed her orientation at that time.

On 3/7/18 at 1300 Staff C was informed of the lack of hand hygiene and lack of BGM cleaning after patient use following. Staff C said, Oh, no she's still in orientation. Staff K was overheard as she repeated she had completed her 4 hours of orientation on 3/3/18 at that time.

On 3/7/18 at 1305 Staff C explained she would have to speak to the Director of Nursing (DON) Staff A and locate Staff K's orientation/competency training documentation.

On 3/7/18 at 1330 during an interview with the DON Staff A when informed of the aforementioned concerns Staff A explained IV lines should have been flushed when disconnected. When asked if Staff K should have cleaned the BGM before attempting to use it on another patient the DON asked the surveyor was it (BGM) dirty, was there blood on it?
When asked to explain if agency Staff K should have been under supervisor and checked off on performance, Staff A said yes, we can't possibly get some one checked off on all skills in 1 day.

A review of the facility's "Standard Precautions Infection Control" policy revision dated 2/2018 documented:
Procedure:
1. Hand hygiene:
A. Perform hand hygiene (soap and water/alcohol based hand gel) upon entering and leaving a patient room, after removing gloves and when indicated after touching any contaminated items or fluids.
3. Equipment:
A. Patient care equipment soiled with blood, body fluid, secretions and excretions are to be cleaned according to facility policy using a hospital approved disinfectant.
B. Ensure that reusable equipment is not used for the care of another patient until it has been appropriately cleaned and reprocessed and that single-use items are properly discarded.

Based on observation, interview and record review, the facility failed to ensure nursing staff updated the plan of care and implemented individualized interventions that addressed changes in skin condition for 1 (#1) of 4 patient's reviewed with alterations in skin integrity out of a total of 7 sampled patient's, resulting in the potential for the less than optimal outcomes for the patient.
Findings include:

On 3/6/18 at 1100 the medical record for patient #1 was reviewed with the Director of Nursing(DON) Staff A. Per review of the medical record the patient was admitted to the facility on 1/5/18 with diagnoses that included endometrial cancer, sepsis and bowel perforation. A review of the nursing admission assessment documented the patient's skin was not intact on her admission.

At that time the DON explained the wound care team were responsible for obtaining and documenting their findings on the patient's skin assessment. A review of the patient's skin assessment dated 1/8/18 documented the patient had 2 wounds. Wound (#1) to her left upper back that was described as excoriation and wound #2 a midline surgical wound that measured 4 centimeter (cm) by 4 cm x 2.5 cm. The wound was characterized with beefy red granulation and purulent drainage. The wound was secured with a dry gauze.

On 2/23/18 the patient's skin assessment per the wound team documented the patient's left upper back wound (#1) was healed. The patient's surgical abdominal wound (#2) had decreased in size and in addition the patient had excoriation (#3) to her bilateral buttocks.

On 3/2/18 at 1232 the wound care team documented the patient's skin was not assessed due to her (#1) being unstable for turning.

On 3/5/18 the wound care team documented the following:
Wound #2 surgical abdominal wound 0.5 x 0.3 x 0.8 full thickness wound with purulent drainage 75 percent beefy red granulation with a drainage pouch for drainage collection.
Wound #3 incontinence dermatitis to bilateral buttocks.
Wound #4 Right lateral neck moisture related with partial skin loss with copious amounts of moderate serous drainage.
Wound #5 Right posterior thigh wound moisture related skin weeping.

On 3/6/18 at 1130 an interview and record review was conducted with Wound Care Treatment Nurse Staff D. Staff D explained that she was 1 of 2 wound care nurses. Staff D said her partner Staff J was following the patient and had assessed the patient on 3/5/18. When queried regarding the treatment plan for patient #1's right lateral neck change in skin condition, Staff D said there were no current orders written for the patients right neck partial thickness skin wound. Staff D said if the wound was draining it should have been kept clean and dry.

On 3/6/18 at 1150 while accompanied by Staff D patient #1 was observed in bed. The patient was orally intubated and connected to a ventilator. The patient was not responsive to verbal command nor tactile stimulation when prompted by Staff D or Staff E. The patient had a nasogastric tube that was connected to low continuous wall suction via her right nare. The patients lips were observed covered with approximately 70 percent of dry necrotic tissue. There was bloody drainage oozing from the patient's mouth. At that time Respiratory Therapist Staff F was paged to the room. Staff D explained the patient needed to be suctioned.

On 3/6/18 at 1153 Staff F was observed as she suctioned the patient (#1) via in-line (closed system) suction for a moderate amount of bloody drainage. Staff F was observed as she suctioned the patient with an oral suction collection tube orally and nasally for a moderate amount of bloody drainage via her left nare. At that time Staff F was asked who was responsible for providing oral care. Staff F acknowledged the patient's lips were dry and necrotic at that time. Staff F said oral care was provided with trach care and suctioning every shift and as needed by her department. Staff F said the nursing staff could perform oral care as well.

When further queried Staff F explained she had not addressed the patient's dry necrotic lips. She said we would have to use a water based protectant. Staff F was observed as she looked in the patient's bedside table and room for a water based lip protectant. There were no swabs or water based lubricants in the patient's room for immediate use.

On 3/6/18 at 1200 patient #1 was observed for a skin assessment that was performed by Staff D. Beneath the patient's mouth bite guard (used to secure the endotracheal tube) a linear ulceration that was approximately 4 centimeters in length was observed with dark pink and necrotic tissue. The patient's right lateral neck was observed as Staff D tilted the patient's head for observation. The patient's right lateral neck and anterior right shoulder area was grossly inflamed with red discoloration that extended from beneath the patient's right chin to the back of the patient's neck onto her right anterior upper shoulder area. There were blisters with copious amounts of serous yellow/blood tinged drainage noted in the creases of the patient's right lower neck and upper right shoulder blade area. There were no protective coverings in place to keep the patient's right anterior neck wound clean and dry.

On 3/6/18 at 1210 Staff F was queried regarding patient #1's change in skin condition. Staff F said the patient required frequent suctioning. She said she noticed the patient's wound beneath the mouth guard and the collection of oral secretions on the patient's right lateral neck approximately one week ago. She said she told the nurse about it. She said she could not recall what nurse she told.

On 3/6/18 at 1220 Staff E was queried regarding the patient's dry and necrotic (dead tissue) lips and her inflamed neck wound. Staff E explained he had not addressed the aforementioned concerns.

On 3/6/18 at 1400 during an interview the DON explained the wound care nurse Staff J should have obtained a treatment order for the change in the patient's skin condition. At that time a review of the patient's "Impaired Skin Integrity" care plan dated 1/5/18 with target date for healing on 3/6/18 documented:
Objective: "Evidence of healing for wounds other than pressure ulcers"
Intervention: Assess for wound pain every shift and as needed, especially during wound care and procedures. Administer analgesia as ordered. Assess non-pressure wounds every shift or with dressing changes. Perform wound care per protocol or as ordered.
However, there were no wound care orders obtained or documented for the patient's right chin and right lateral neck skin wounds. There were no updates documented on the patient's impaired skin integrity care plan that addressed in the changes in the patient's skin integrity.

On 3/7/18 at 1220 an interview was conducted with wound care nurse Staff J. Staff J confirmed she had performed patient #1's skin assessment on 3/5/18 and noted the skin break down on the patient's right lateral neck. Staff J said the patient had partial thickness skin loss to her neck that was moisture related. Staff J said she called the physician but failed to write a treatment order or document that she called the physician. Staff J said she did not notify the patient's family of the change in her skin condition. Staff J said she did not update the skin care plan. Staff J said she did not write an incident report. Staff J explained a skin barrier and an absorbent gauze would had been the recommended treatment. Staff J said on 3/5/18 she was sick and left early before writing the order. Staff J was asked if she had seen patient #1 today. Staff J said she had not.

On 3/7/18 at 1240 while accompanied by Staff J patient #1 was observed in her room in bed on her back facing the door. A pillow beneath the patient's head was saturated with a large amount of yellow-blood tinged drainage that was pooled from the right side of the patient's mouth to the back of her right ear and onto her right anterior upper shoulder area. A nasogastric tube was intact to the patient's right nare and was connected to low continuos wall suction. The patient's left nare was observed with a large amount of blood drainage. There a small amount of bloody drainage observed pooling from the patient's mouth. At that time Staff J was observed as she use the oral suction tube and suctioned the patient's mouth and left nare. Staff J was then observed as she tilted patient #1's head toward the window. There was no protective dressing observed to protect the patient's right lateral partial thickness left wound from the bloody drainage. The patient's right left neck was edematous. There were fluid filled blisters observed on the patient's right anterior neck region. There was increased redness noted. Staff J was overheard as she said this is not good. I will get someone to help me with her.

On 3/7/18 at 1230 an interview was conducted with Staff F the assigned Registered Nurse (RN) for patient #1. When asked to explain if the patient had received morning (am) care or had been turned and/or repositioned Staff F explained she had saw the patient earlier during her shift. Staff F said the patient had a bath on the night shift. However, Staff F was unable to explain why the patient was found lying in a pool of blood tinged drainage that was pooling from her mouth downward onto her right lateral neck and right anterior shoulder. Staff F could not explain why the patient's was observed with her left nare filled with oozing bloody drainage. Staff F could not explain why the patient's lip were cracked and necrotic.

On 3/7/18 at 1310 during an interview the DON offered no further explanation when queried regarding why the patient's right lateral neck partial thickness wound was not addressed and why the patient was observed in her room in the aforementioned condition.

Based on observation, interview and record review, the facility failed to ensure 1 (Staff K) of 3 Patient Care Technicians (PCT's) were supervised during orientation and failed to ensure PCT skill checks/competencies were performed for 1 (Staff K) of 3 PCT's reviewed for competencies, resulting in the potential for less than optimal patient outcomes for 9 patients assigned to Staff K.
Findings include:

On 3/7/18 at 1240 while accompanied by Staff J patient #1 was observed in her room in bed on her back facing the door. A pillow beneath the patient's head was saturated with a large amount of yellow-blood tinged drainage that was pooled from the patient's mouth to her right anterior neck and the back of her right ear. A nasogastric tube was intact to the patient's right nare and was connected to low continuous wall suction. The patient's left nare was observed with a large amount of bloody drainage. The patient did not respond to verbal command. A pile of linens and gowns were also observed in an upright chair near the patient's bed.

On 3/7/18 at 1245 Staff K was observed as she entered patient's (#1's) room. Staff K said she was an agency PCT who was called in to work today. Staff K said she arrived at 1030. Staff K said she was assigned 9 patients. Staff K said she needed to perform a fingerstick for the patient's blood sugar. When asked to explain if the patient had been turned or repositioned, and if the patient had been provided morning (am) care. Staff K stated, "Me myself I have not turned her today or did her bath." Staff K said "I have other tasks to do now". She said, "I will get back to her after I check hers and my other patient's blood sugars." At that time Staff K was observed as she proceeded with checking patient #1's blood sugar after donning a pair of gloves. After she completed checking patient #1's blood sugar Staff K was observed as she discarded the used lancet and her gloves and exited the patient's room without cleaning the blood glucose monitoring device (BGM) or performing hand hygiene.

On 3/7/18 at 1249 Staff K was observed as she entered the room adjacent to patient #1's room. Staff K was overheard as she asked the patient their name. She (Staff K) explained she was going to check their blood sugar. At that time the surveyor requested Staff K exit the patient's room and speak with the surveyor. Staff K was asked to explain why she did not clean the BGM. Staff K stated, "I was going to clean it in that patient's room." Staff K when prompted said I'll go back and clean it in patient (#1's room). Staff K then returned to patient #1's room. She obtained a bleach wipe and proceeded to wipe down the outer carrying case for the BGM device. Staff K had to be prompted by the surveyor to clean the actual device. Staff K was overheard as she stated, "No one ever told me to clean the thing." Staff K was then observed leaving the patient's room without performing hand hygiene.

On 3/7/18 at 1255 the Chief Nursing Officer Staff C was observed as she entered the room. Staff C was overheard as she asked Staff K "who are you." Staff K was not wearing a badge. Staff K was wearing burgundy scrubs with a college logo. Staff K explained she was an agency PCT who worked 4 hours previously on Saturday 3/3/18 for orientation. Staff K was overheard as she explained she completed her orientation at that time. At that time Staff C was informed of the lack of hand hygiene and lack of BGM cleaning after patient use following. Staff C said, Oh, no she's still in orientation. Staff K was overheard as she repeated she had completed her 4 hours of orientation on 3/3/18 at that time.

On 3/7/18 at 1305 Staff C explained she would have to speak to the Director of Nursing (DON) Staff A and locate Staff K's orientation/competency training documentation.

On 3/7/18 at 1330 during an interview with the DON Staff A when informed of the aforementioned concerns Staff A explained IV lines should have been flushed when disconnected. When asked to explained if agency Staff K should have been under supervision and checked off on performance and competencies, Staff A said we can't possibly get some one checked off on all skills in 1 day.

On 3/7/18 at 1335 a review of a form titled "Nursing Agency Shift Performance Evaluation" dated 3/7/18 and signed by Staff K and PCT Staff N and O on 3/7/18 revealed Staff K had not been evaluated for #3 - Performing technical skills competently and in accordance with policy, procedure and age specific criteria. That section on the form was left blank and not scored. In addition, there were no areas on the form that evaluated Infection Control Prevention training or adherence to Infection Control practice measures.

On 3/7/18 at 1338 when queried regarding the lack of skills training or evaluation of competency for technical skills and Infection Control prevention the DON offered no further explanation at that time.

A review of the job description and competencies for PCT revision date August 2016 documented the following:
Job Function:
"Performs a variety of basic patient care activities under the direction of a registered nurse and/or preceptor which may include, but not limited to, performing...blood glucose monitoring...".