HospitalInspections.org

Based on patient medical record review, facility policy and procedure review, nursing care plan recommendations, and staff interview, the registered nurses supervising the care and evaluation of patients failed to implement the policy related to "Guidelines and Protocols-Nursing" for wounds and Braden scale assessments and failed to implement the nursing care plan for repositioning for 4 of 5 patients (pts. N1, N2, N3 and N5).

Findings:
1. At 12:00 PM on 4/13/11, review of the policy and procedure "Guidelines and Protocols-Nursing" Number S05-G, with a most recent revised date of 10/10/08, indicated:
a. on page 3 under "Wounds", it read: "Photos--Within 24 hours of admission and every week...Braden scale--With initial wound assessment and every week thereafter"

b. on page 3 under "Pain", it read: "Assessment and documentation--On admission for all patients; every shift for patients...every 4 hours if patient has pain greater than 4/10 until resolved and
30 - 60 minutes post intervention."

2. Nursing care plans for patients N1 through N5 had documentation on page 4 under "Goals: Maintain skin integrity. Promote wound healing." that the staff should "Turn & reposition q 2 hrs." the patients due to Braden Scale skin assessments which indicated these patients were at high risk for, or had, wounds

3. Review of patient medical records during the survey process of 4/13/11 and 4/14/11, documentation in the medical records indicated:
a. Pt. N1 had:
A. Repositioning documented greater than every two hours, per the nursing flowsheet, on page 6, for:
I. an undated flowsheet page had a notation of repositioning at 1800 hours and no documentation between 1800 hours to 0600 hours
II. 12/17/09 had a notation at 1600 hours with the next notation at 1900 hours
III. 12/24/09 with a notation at 1000 hours and the next at 1400 hours; and with a notation at 0300 hours and no documentation at either 0500 hours or 0600 hours
IV. 12/28/09 with a notation at 0900 hours and the next at 1200 hours
V. 12/30/09 with a notation at 1200 hours and the next at 1800 hours
VI. 12/31/09 was lacking a notation of repositioning from 0700 hours to 1900 hours
B. Documentation related to the follow up of pain medication within 30 to 60 minutes, as per facility policy, was lacking for the following:
I. on 12/23/09, medication was given at 2100 hours and the next pain follow up was at 2300 hours
II. on 12/28/09, medication was given at 2200 hours and the next pain follow up was at 2400 hours

b. Pt. N2 had:
A. repositioning documented greater than every two hours, per the nursing flowsheet, page 6, for:
I. on 12/24/09, a repositioning notation was made at 1700 hours, with the next notation at 2000 hours
II. on 12/26/09, a repositioning notation was made at 1800 hours, with the next notation at 2100 hours
III. on 1/2/10, a repositioning notation was made at 1400 hours, with the next notation at 1700 hours
IV. on 1/13/10, a repositioning notation was made at 1200 hours, with the next notation at 1900 hours
B. Per the nursing flow sheet of 12/27/09, on page 7, it was indicated that pain follow up within 30 to 60 minutes of medicating the patient for pain, per facility policy, was lacking after medication was given at: 0800 hours and 1200 hours

c. Pt. N3 was admitted on 12/18/09 with a left heel wound/decubitus and did not have the admission wound photo taken until 12/21/09, (not within 24 hours of admission as per policy)

d. Pt. N5 had:
A. per the nursing documentation on page 6, of the nursing flow sheets, that: on an undated page, a repositioning notation was made at 0400 hours, and was lacking documentation at the 0600 time
B. on 1/18/10, a repositioning notation was made at 0300 hours, and was lacking documentation at the 0500 time or the 0600 time frames
C. The Braden Scale skin assessment was not done on admission, 1/5/10, as per facility policy (first one done was dated 1/12/10)

4. Interview with staff members NA and NB at 1:35 PM on 4/14/11 indicated:
a. documentation was not provided by nursing as noted for patients N1, N2, N3 and N5 in regards to repositioning every 2 hours and pain intervention follow up within 30 to 60 minutes
b. pt. N3 was lacking a photo of a heel wound within 24 hours of admission
c. pt. N5 was lacking an admission Braden Scale skin assessment

Based on tour of the facility (observation), policy and procedure review, and staff interview, the infection control practitioner failed to ensure policy implementation related to precaution signs being posted on patient doors for those patients requiring isolation precautions (pts. in rooms 701, 703, 704, 706 and 715).

Findings:
1. Review of the policy IC III-5 "Enhanced Contact Precautions" (no date of review/revision noted), indicated:
a. under "Procedures" (for patients determined to need infection precautions), it read in section B., "Specific Procedures:...2. A sign reading "Contact Precautions" will be posted on the door..."

2. Review of the policy IC III-3 "Determination of Isolation" (no date of review/revision noted), indicated:
a. under "Policy", it read in #9., "Appropriate signage will be placed."

3. At 10:50 AM on 4/13/11, while on tour of the 7th floor nursing unit in the company of staff member NB, it was observed that rooms 701, 703, 704, 705 and 715 had door hanging equipment that contained non sterile gloves, masks and paper gowns as PPE (personal protective equipment) used for patients in isolation. Other rooms on the nursing unit with these door hangings, had signs indicating the type of precautions needed.

4. Interview with staff member NB, while touring at 10:50 AM on 4/13/11, indicated:
a. signs are to be posted on patient doors, along with the PPE provided
b. the rooms as listed in 6. above were lacking such posting