HospitalInspections.org

Based on medical record review, policy review and staff interview, it was determined that the registered nurse (RN) failed to supervise and evaluate the nursing care for 4 of 5 patients (Patient #'s 1, 2, 3 and 4) in the sample. Findings include:

The hospital Registered Nurse "Job Description" stated, "...Supervises...and assures implementation of plan of care...integrates the medical care plan into the provision of nursing care...Assures that documentation in the medical records are complete...Provides nursing care to meet patient's needs...Adheres to established policies and procedures...Performs wound care in accordance with policy, utilizing proper documentation tools..."

The hospital policy entitled "VAP (Ventilator Associated Pneumonia) Bundle" stated, "...Nursing and/or RT (respiratory therapy) will provide oral care every 4 hours..."

The hospital policy entitled "Gastric/Duodenal Tube Guidelines: PEG (percutaneous endoscopic gastrostomy), Gastrostomy Tube, Small-Bore Nasal Tube, Nasogastric Tube, Orogastric" stated, "...For PEG and NG (nasogastric) tubes...Check Gastric Residual Volume (GRV) every 4 hours..."

The hospital policy entitled "Pain Management, Assessment and Intervention Protocol" stated, "...indicate...pain on a scale from 0-10 with 0 being no pain and 10 being the worst pain imaginable...If no pain indicated, pain will be assessed every shift (12 hours) thereafter. If pain stated, patient will be assessed about every 4 hours..."

The hospital policy entitled "Wound Program Overview and Initiation Process..." stated, "...MD (medical doctor) treatment ordered and instituted..."

The hospital policy entitled "Guidelines and Protocols, Clinical" stated,"...Document position...reposition...every 2 hours...Non-bedfast patients out of bed (OOB) to chair...twice a day (BID) minimum..."

Medical record review revealed:

A. Patient #1

1. Physician orders dated 8/31/16 included orders for: - mechanical ventilation- nursing and/or respiratory therapy to provide oral care every 4 hours

2. No evidence that oral care was provided every 4 hours:
9/2/16: 5:00 PM - 9/3/16 6:00 AM (13 hours)
9/5/16: 8:40 AM - 7:45 PM (11 hours)
9/6/16: 11:48 PM - 9/7/16 8:35 AM (8 hours 37 minutes)
9/7/16: 11:50 PM - 9/8/16 9:00 AM (9 hours 10 minutes)

These findings were confirmed by Director of Quality Management A on 10/6/16 between 12:09 PM and 12:15 PM.

B. Patient #2

1. Physician orders revealed:
9/16/16: NG tube and tube feeding
9/19/16: apply MediHoney moistened gauze to abdominal wound daily

2. The "24 hour Patient Record & (and) Plan of Care" documentation revealed no evidence that:

a. the nurse measured the patient's gastric residual volume on the following dates: 9/20, 9/23, 9/24, 9/26, 9/27, 9/28, 9/29 and 10/3/16

b. the nurse assessed the patient's level or existence of pain:
- 9/26/16 at 10:00 AM: pain rated 4-6; pain not reassessed until 11:00 PM (13 hours later)
- 10/2/16: pain assessed at 10:00 PM; however, pain not assessed again until 10/3/16 at 10:00 PM (24 hours)

c. wound care was performed on the following days: 9/22, 9/23 and 9/25/16

Findings a. and b. were confirmed by Director of Quality Management A on 10/4/16 between 1:35 PM and 1:50 PM.

Finding c. was confirmed by Director of Quality Management A and Wound Care Nurse A on 10/5/16 at 1:10 PM.

3. The "24 Hour Patient Record & Plan of Care", dated 9/21/16, revealed the following:
- was to be turned and repositioned every 2 hours
- no evidence that the patient was turned between 1:00 AM and 6:00 AM (5 hours)

This finding was confirmed by Director of Quality Management on 10/4/16 at 1:45 PM.

C. Patient #4

1. Physician orders dated 9/7/16 included orders for:
- PEG tube and tube feedings

2. The "24 hour Patient Record & Plan of Care" documentation revealed no evidence that the nurse:

a. measured the patient's gastric residual volume on the following dates: 9/22, 9/23, 9/28, 9/29, 9/30, 10/1 and 10/2/16

b. assessed the patient for level or existence of pain:
- 9/20/16 at 8:00 AM: pain rated 7; pain not reassessed until 8:00 PM (12 hours later)
- 9/28/16 at 3:00 PM: pain rated 5; pain not reassessed until 8:00 PM (5 hours later)

These findings were confirmed by Director of Quality Management A on 10/5/16 between 11:05 AM and 12:50 PM.

D. Patient #3

1. Review of "24 Hour Patient Record & Plan of Care" documentation revealed:
- was to be OOB to chair BID

a. No evidence that the patient was OOB to a chair BID on the following dates:
9/21 - 9/22, 9/24 - 9/27, 10/1 - 10/2 and 10/4/16

These findings were confirmed by Director of Quality Management A on 10/5/16 between 10:50 AM and 11:05 AM.

Based on observation and staff interview, it was determined that the hospital failed to maintain cabinets in a manner to assure patient safety in 2 of 34 patient rooms (Room 501 and 514) observed on the environmental tour. Findings include:

During a hospital tour on 10/4/16, the following was observed:

A. Room 501
- one (1) cabinet in the ante-area of the patient room, was stuck in closed position

This finding was confirmed at the time of observation by Staff Nurse A on 10/4/16 at 9:20 AM.

B. Room 514
- two (2) cabinets used to house patient belongings had to be pried open to access, and rust was found at the base and side of each interior cabinet, where the cabinet door closed

This finding was confirmed at the time of observation by Administrator A on 10/4/16 at 11:30 AM.

Based on observation, policy review and staff interview, it was determined that the infection control officer failed to ensure that staff adhered to infection control measures for 2 of 11 patients (Patient #'s 2 and 3) in the sample observed with indwelling urinary catheters and for 9 of 27 patients (Patient #'s 2, 3, 4, 5, 6, 8, 9, 10 and 11) observed who required periodic suctioning and/or tracheostomy care. Findings include:

Interview with Director of Quality Management A on 10/4/16 at 9:00 AM revealed that his/her role included Infection Control Manager as part of his/her responsibility.

The Director of Quality Management "Job Description" stated, "...The Director of Quality Management is responsible for coordination, development and evaluation of all outcome activities including but not limited to:...Infection Control...Implements IC (infection control) plan..."

The Infection Control/Employee Health Nurse "Job Description" stated, "...Plans, organizes, implements, evaluates, and directs the Infection Control Program in accordance with...current CDC (Centers for Disease Control and Prevention) recommendations..."

The CDC Healthcare Infection Control Practices Advisory Committee "Guideline for Prevention of Catheter Associated Urinary Tract Infections 2009" stated, "...Proper Techniques for Urinary Catheter Maintenance...Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor...Empty the collecting bag regularly...and prevent contact of the drainage spigot with the nonsterile collecting container..."

The hospital policy entitled "Guideline's and Protocols, Clinical" stated, "...To ensure quality patient care, certain standards of care must be upheld. The following table outlines basic tasks and designates the minimum frequency with which these tasks must be performed to maintain quality care...Suction canister weekly or when 2/3 full, whichever comes first..."

The hospital policy entitled "Hand Hygiene" stated, "...Effective hand hygiene is...basis for effective Infection Control...hand hygiene...before and after every patient contact...When moving from high contamination patient care activities to cleaner activities...before donning either sterile or non-sterile gloves...between glove changes and after removing gloves, After any contact with body fluids, dressings...after touching hospital surfaces...hand hygiene...after touching secretions, immediately after removing gloves..."

A. During a hospital tour on 10/4/16 between 9:15 AM and 10:45 AM, the urine collection bag and spigot were observed touching the floor for the following patients with urinary catheters:

1. Patient #3

This finding was observed and confirmed by Charge Nurse A on 10/4/16 at 9:18 AM.

2. Patient #2

This finding was observed and confirmed by Staff Nurse A on 10/4/16 at 9:50 AM.

B. During a hospital tour on 10/4/16 between 9:15 AM and 10:45 AM, suction canisters for Patient #'s 2, 3, 4, 5, 6, 8, 9, 10 and 11 were observed:
- containing secretions
- not labeled with date and time initiated

These findings were reviewed and confirmed by Director of Quality Management A on 10/4/16 at 3:10 PM. Interview with Respiratory Therapist B on 10/5/16 at 11:10 AM revealed that the standard was to change suction canisters weekly.

C. On 10/4/16 between 9:35 AM and 10:00 AM, the following technique was observed during Patient #11's tracheostomy care performed by Respiratory Therapist A:

- performed hand hygiene
- donned clean gloves
- donned sterile glove on right hand only
- attached suction catheter to suction tubing and attached to wall suction canister
- suctioned patient
- removed sterile glove, leaving previously donned gloves on hands
- detached suction catheter
- attached oral hygiene wand to suction tube and attached to wall canister
- performed oral care
- detached wand from suction tube
- connected the open end of the suction tube to wall suction canister
- opened tracheostomy care kit
- retrieved supplies
- touched wall with back of right glove
- donned sterile glove over right glove
- performed tracheostomy care
- removed gloves
- sanitized hands

Respiratory Therapist A failed to perform hand hygiene and change gloves:
- before every patient contact
- after removing gloves
- before donning sterile gloves
- after touching hospital surfaces

These findings were witnessed by Director of Quality Management A. On 10/4/16 at 1:15 PM, Director of Quality Management A confirmed that Respiratory Therapist A failed to adhere to infection control requirements for hand hygiene and glove changes.