HospitalInspections.org

Based on interview and record review, the facility failed to ensure nursing implemented and carried out physician orders for 2 of 2 patient records reviewed (Patient IDs # 12 and 3).

Findings:
Record review of Policy # WC-3.2, "Wound Assessment by Admitting Nurse and Wound Care Team", was completed. The policy states "The admitting wound care team member will complete a thorough head to toe skin assessment of each patient within 72 hours of admission. This will include taking photographs and completion of the following forms: Wound assessment, wound care orders, and surface selection. All wounds will be assessed on admission, weekly and as needed for changes. The wound care team will document on the Daily Treatment Record for each wound care treatment completed."

Interview 9/27/22 11:25 a.m. with Patient (ID# 12), patient stated "they don't always do my dressing change when they are supposed to." When asked for clarification of the statement, the patient stated "if I am at therapy or at an appointment, they skip me and don't come back."

Interview 9/27/22 1:30 p.m. with Staff Registered Nurse (ID# 70) revealed that the wound care policy calls for a full skin assessment within 24 hours of admission on weekdays, including wound photographs. She stated they photograph wounds weekly. She reviewed and clarified the medical record for Patient (ID # 70) and stated the patient had wound care orders which stated "wound care team. 3x/wk. Use dry gauze and hypofix." (tape). She stated Patient (ID # 70), should have three times weekly wound care by wound care team. She stated they do not have format or procedure for documenting a specific wound exam or assessment, only that a wound assesment was performed, so she was unable to show surveyor what the wound appearance/assessment was in the medical record.

Interview with wound care RN (ID# 70) stated that all patients are see upon admission and weekly by the wound care team. Upon reviewing medical record for patient (ID # 3), she confirmed that wound care assessments were not performed weekly as per policy.

Record review of the medical record for Patient (ID# 12) revealed he had history of Left Ventricular Assist Device resistent driveline infection necessitating long-term antibiotics. He had provider orders, most recently placed on 9/7/22 1: 35 p.m., which stated "wound care team. 3x/wk. Use dry gauze and hypofix." (tape).
Staff (ID #70) (RN Wound care team) validated the medical record had the following wound care assessments:
9/12/22 - "Daily wound care treatment record". Assessment completed. Photograph affixed. Date present. No time of assessment.
9/15/22 - "17:00 - Change dressing initialed. No documented assessment findings.
9/19/22 - No time. Change dressing initialed. No documented assessment findings.
9/21/22 - 10:30 a.m. "Pt refused." Staff initals were present. There is no written note describing why patient refused or physician notification.
9/22/22 - No time. "Dr Appt." Staff initials.

In summation, in the 14 day period between 9/12/22 and 9/26/22, Patient (ID #70)had 3 of the 6 ordered wound care assessments/treatments performed on a critical implanted device exit site wound which has prior history of infection and extremely high risk. Only 1 of 6 ordered encounters included a nursing skin assessment documented.

Medical record review for patient (ID#3) showed he was admitted to the facility 4/2/2022 and discharged 4/27/2022. Initial assessment completed by the wound care team was performed 4/3/2022. Followup assessments were performed 4/5/2022 and 4/18/2022.


46010

Based on observation, interview and record review, the facility failed to ensure that a registered nurse, who was currently assigned to patient care, had current competencies in 1 of 2 personnel files reviewed (staff ID # 69).

Findings Include:
Observation during tour 9/27/22 at 1140 a.m., staff registered nurse ID #69 was assigned to Patient (ID # 12). Patient (ID# 12) had a Left Ventricular Assist Device.

Interview 9/27/22 at 11:45 a.m. with Staff ID #69, she stated she was the registered nurse assigned to care for patient (ID #12) today. She denied having any prior experience or training/education for care of a patient with Left Ventricular Assist Devices (LVAD).

Interview 9/27/22 at 1:55 p.m. with CNO Staff (ID# 53), he stated that nurses had competency and training for LVADs. He stated that the "company representative had come to provide training to ICU staff and house supervisors".

Record review 9/27/22 at 2:45 p.m. with CNO staff (ID #53), of "Heartmate2, 3 LVAD Training" record dated "06-15-22" revealed that staff registered nurse ID #69 was not listed for training and did not have a signed "compentency assessment documentation" validation form.

Record review 9/28/22 at 11:45 a.m. with CNO (ID #53) revealed employee file for staff RN (ID #69) failed to demonstrate competency or training records for LVAD devices. He stated they trained "ICU staff and house supervisors" and the patient had been transferred out of ICU. He confirmed no staff training had been performed for nurses outside of ICU.

Based on observation, interview, and record review, the facility failed to maintain the hospital environment to ensure the safety of the patients.

Findings included:
A) Ceiling tile staining and peeling paint:
Observation during facility tour with Maintenance Technician Staff ID #64 on 9/27/22 at 11:20 a.m., revealed a "clean storage unit" with clean linen and clean supplies to have 3 ceiling tiles with brown liquid stains and 1 overhead ceiling light with brown liquid mark dried in it. The wall inside the storage room, adjacent to the entry door, was noted to have peeling paint and flecks of paint on the floor.

Interview with Staff ID #64 on 9/27/22 at 11:20 a.m., he stated "it's probably humidity from adjacent air conditioing vent." He stated "we don't come in here often." He denied any open work orders for assessment or repair of either the peeling wall paint or assessment/repair of ceiling staining. He stated the wall paint was probably pelling from having been hit with equipment or supplies.

Interview with CEO Staff ID #54 on 9/28/22 at 2:45 p.m., she stated that HHS is contractually bound to provide building maintenance services and they should be putting in work orders and completing building maintenance.

Record Review of contractual agreement titled "Statement of Work Agreement", dated 4/1/2022, showed the following: "This Statement of Work ("SOW") is an agreement by and between CHG Hospital Houston, LLC dba Cornerstone Hospital Houston Clear Lake ("FACILITY") and HHS Senior Living, LLC ("HHS") and is governed by and incorporated by reference the terms and conditions contained in the Master Services Agreement for Housekeeping, Culinary and Integrated Facilities Management and Services (the "MSA"), by and between and HHS and Cornerstone Healthcare Group Holding, Inc. ("CHG"), dated April 1st, 2022, and describes the Services to be provided by HHS to FACILITY. SCOPE OF SERVICE RESPONSIBILITIES:
HHS is responsible for the management of each listed purchased outside service or Facility expense: Building Aesthetics and Interior Finishes."

B) Storage of used ventilators and "dirty"mattress in the clean central supply area.
Observation during facility tour with Maintenance Technician Staff ID #64 on 9/27/22 at 11:35 a.m., revealed 6 ventilators and 1 rolled up mattress "dirty mattress" in the large central supply storage room, where the majority of the hospital's clean supplies are stored. There was no signage designating clean versus dirty or contaminated equipment.

Interview with Staff ID #66 on 9/27/22 at 11:37 a.m. revealed that 4 draped ventilators are "rented" ventilators being stored there, waiting for outside vendor to pick up. 2 additional ventilators were present, 1 with a circuit attached, and both were undraped. She was unable to articulate if the ventilators were clean or dirty. She stated that they were ventilators owned by the faciity and awaiting pickup for repair. She validated that the rolled up patient mattress laying behind the ventilators, with a sign on it that stated "Dirty!!!!Do not use!! Mattress waiting to be picked up for deep clean" was a mattres which was waiting to go out for repair/pickup.

Record Review of facility policy IPC 08.02 titled "Cleaning and Disinfection of Equipment, Devices and Supplies", reviewed 01/22, stated "medical equipment shall be taken to soiled utility area when the equipment needs to be cleaned and disinfected..." "Clean equipment will be tagged/labeled as clean, covered with a clean barrier such as a bag, and placed in a designated for clean items only. There must be signage to identify the clean items only area."

Based on interview and record review, the facility failed to perform infection control risk assessment (ICRA) annually per facility policy and failed to ensure completed ICRA assessments were performed prior to construction.

Findings include:

Interview with interim director for infection control, staff ID #52 on 9/27/22 at 2:55 p.m., revealed that she had not seen an annual infection control risk assessment (ICRA).

Interview with director of facilities management, staff ID # 61 on 9/28/2022 at 11:05 a.m., he stated he was not aware of company policy requiring annual infection control risk assessments. He stated he was not aware of the need to perform ICRA assessments with a multi-disciplinary team.

Record review on 9/27/22 3:05 p.m. of Policy # ICP.01.03 "Infection Control RIsk Assessment (ICRA)", reveiwed "21", the policy stated "the infection control practitioner of the hospital will assess the risk of acquisition and transmissions of infectious agents based on prevalence, virulence, and hospital and employee preparedness. The following considerations will be addressed annually... 4. the hospital reviews and identifies its risks at least annually and whenever significant changes occur with input from, at a minimum, infection control personnel, medical staff, nursing and leadership."

Record review on 9/28/22 11:00 a.m. with staff ID #61, he verified that the ICRA forms which had been completed for replacement of air conditioning duct work had been performed by himself, a contruction project manager and "sometimes" included an infection control practitioner. He verified the following ICRA forms were incomplete:
"Project# HVAC" (Kitchen), Dated "5/2/22 to 5/6/22" Interim Life Safety Checklist, there is a blank ICRA Evaluation date.
"Project#HVAC" (A wing), Dated "5/23/22 to 5/27/22" Interim Life Safety Checklist, there is no project manager listed.
"Project#HVAC" (A wing), Dated "5/23/22 to 6/7/22" Interim Life Safety Checklist, there is no project manager listed.

Based on record review, observation and interview, the facility failed to promote infection control practices through prevention and surveillance to avoid the transmission of infection by:
A. Failed to ensure isolation precautions were followed by patient family members.
B. Failed to ensure there was a process for reporting critical test results that would require isolation precaustions for discharged/transferred patients.
C. Failed to ensure expired tube feeding formula was removed from unit stock/patient care areas.

Findings included:

A. Record review of the facility policy revised 10/2020, "Patient and Family Education" stated patient/family education shall begin at the time of admission being completed by the nurse ...

Observation during rounds on 09/27/2022 at 1100 of the intensive care unit revealed family members of patient (ID#6) on contact isolation, were not following infection control practices.

Observation on 9/27/2022 at 11:45 AM showed family members in contact isolation patient (ID# 11) exit the patient's room and walk to the nurse's station wearing gown and gloves. Staff RN (ID# 59) instructed the family member to return to the patient's room.

Interview with nurse (ID# 57) about the family member who were sitting in the room with a mask only, stated "the patient (ID#6) had pseudomonas in her sputum, and klebsiella in her urine".
She promptly got up and educated the family about the patient's (ID#6) infection control status and returned stating the patients (ID#6) husband, said "it's his wife and he's not doing that". The nurse (ID#57) went back to documenting in the chart.

During interview with staff RN (ID # 59) on 9/27/2022 at 11:55 AM, he confirmed the above observation and stated that the family members should not have exited the room wearing gown and gloves. He stated that patient (ID# 9) was on contact isolation for Methicillin-resistant Staphylococcus aureus (MRSA).

B. Record review of facility policy titled " Critical Test Reporting" dated 10/2020 showed the following information:
All critical values and critical tests will be called to physician or designee within one hour of receiving results and logged as per policy...
Any positive culture will be called to staff and documented as a critical value.

Record review of medical record for patient (ID# 3) showed patient was discharged 4/27/2022, lab result received dated 5/4/2022 with detection of Candida auris.

Interview with Director of Case management (ID# 72) on 9/28/22 at 12:36 PM, she stated that if a patient is discharge with pending labs and/or cultures is is communicated to the accepting facility. It is up to the accepting facility to isolate the patient until the results are received. She stated that the facilities are verbally notified via telephone.

Staff (ID# 72) confirmed there was not documentation in patient's (ID #3) medical record to show if the accepting facility was notified of pending tests and results that were received.

C. Observation during rounds on 09/28/2022 at 1425 with the CNO (ID#53) revealed 17 bottles of expired tube feeding, Vital HP-High Protein, 1-liter bottles were found on the back of the shelf of the supply room in the C-wing.

Nine (9) additional 1-liter bottles of expired Vital HP-High Protein tube feeding were also found on the shelf of the supple room in the ICU.
The tube feeding in both the C-wing and ICU expired on July 1, 2022.

Interview during the tour with the CNO (ID#53) verified the bottles were expired and he asked the staff to pour the feeding down the sink.


37490