HospitalInspections.org

Based on document review and interview, nursing services failed to ensure call lights were answered in a timely manner in 3 of 3 patient rooms (Room 214, 215, and 216) reviewed; failed to ensure prevention and treatment of pressure ulcers in 1 of 10 (P4) patients reviewed; and failed to document completion of peri-care, turns, transfers, bath, and linen change completed daily in 2 of 9 inpatient days reviewed (12/24/24 and 12/25/24).

Findings include:

1. Review of policy/procedure titled, "CORE: Clinical Guidelines for Pressure Injury," H-PC 10-004, release date 06/2022; indicated under Purpose: This policy and procedures establish guidelines for the Registered Nurses (RN) role in preventing and treating pressure injuries based on Braden Risk score and subscales. Under Policy: 2. All patients are considered at risk for pressure injuries. Therefore, patients are routinely screened to determine their Braden risk level: b. Daily. 5. Standard interventions for all patients can include but are not limited to: c. Repositioning orders (minimum every two-hour turns).

2. Review of policy/procedure titled, "Activities of Daily Living," SAU-QL-10, release date 10/2022; indicated under Procedure: 7. Assistance is provided to patients who need extensive or total assistance with maintenance of nutrition, grooming, and personal and oral hygiene.

3. Review of Unit Activity Report for dates from 12/17/2024 through 12/25/2024 indicated patient call lights were not answered in a timely manner 177 times the call light was activated out of 327 call light activations. The report indicated the following:

a. Room 214 call light report indicated the call light was not answered timely 118 out 210 times the call light was activated. These include but are not limited to 12/17/2024-21 minutes, 6 minutes, and 5 minutes. 12/18/2024-34 minutes, 33 minutes, and 15 minutes. 12/19/2024-16 minutes, 15 minutes, and 9 minutes. 12/20/2024-37 minutes, 35 minutes, and 28 minutes. 12/21/2024-1 hour 27 minutes, 1 hour 23 minutes, and 41 minutes. 12/22/2024-34 minutes, 25 minutes, and 13 minutes. 12/23/2024-31 minutes, 24 minutes, and 20 minutes. 12/24/2024-1 hour 18 minutes, 41 minutes, and 19 minutes. 12/25/2024-1 hour 8 minutes, 46 minutes, and 27 minutes.

b. Room 215 call light report indicated the call light was not answered timely 20 out 37 times the call light was activated. These include but are not limited to 12/17/2024-17 minutes and 5 minutes. 12/18/2024-20 minutes, 17 minutes, and 14 minutes. 12/19/2024-25 minutes, 10 minutes, and 6 minutes. 12/21/2024-8 minutes and 6 minutes. 12/24/2024-18 minutes, 13 minutes, and 6 minutes. 12/01/2024-16 minutes, 15 minutes, and 9 minutes.

c. Room 216, P4's room, call light report indicated the call light was not answered timely 39 out 80 times the call light was activated. These include but are not limited to 12/17/2024-26 minutes, 10 minutes, and 6 minutes. 12/18/2024-19 minutes, 13 minutes, and 12 minutes. 12/19/2024-18 minutes, 13 minutes, and 12 minutes. 12/20/2024-30 minutes, 29 minutes, and 19 minutes. 12/21/2024-11 minutes, 6 minutes, and 5 minutes. 12/22/2024-21 minutes, 10 minutes, and 9 minutes. 12/23/2024-50 minutes, 28 minutes, and 19 minutes. 12/24/2024-25 minutes and 5 minutes.

4. Review of P4's MR indicated MR lacked documentation of daily skin assessments completed on 12/19/24 - 12/23/24. MR lacked documentation of daily Braden assessment completed on 12/18/24, 12/22/24 and 12/23/24.

5. Interview with P12 (current patient) on 01/16/25 at approximately 4:00 p.m., indicated the call lights are not answered timely unless their family is there.

6. Interview with P11 (current patient) on 01/16/25 at approximately 3:45 p.m., indicated sometimes it takes a long time to get their call light answered.

7. Interview with A7 (Nursing Supervisor) on 01/16/25 at approximately 4:30 p.m., indicated patients are rounded on every hour and turned/repositioned every two hours and toileted at that time or as needed. A7 indicated the facility does not have a policy indicating the time to answer a call light, but the goal is to answer a patient call light timely.

Based on document review and observation the facility failed to maintain a clean and sanitary environment by not ensuring patient rooms were cleaned daily in 9 of 9 days reviewed (12/17/24 - 12/25/24); and failed to ensure 2 out of 2 patient rooms were clean (P11 & P12).

1. Review of policy/procedure titled, "Cleaning of Shared Patient Medical Equipment," H-IC 02-015, release date 06/2022; indicated under Purpose: This policy establishes guidelines to assure that shared patient medical equipment has been cleaned and disinfected prior to use on other patients so that transmission of infections is minimized. Under Policy: 3. Ensure that all equipment is cleaned, disinfected using the appropriate contact time.

2. Review of policy/procedure titled, "Patient Room Cleaning - Daily Cleaning Service," policy number 16, review date 04/2024; indicated under Zone ONE (Bed): Use the first cloth to clean all parts of the bed. Wipe down all bed rails, headboards, and footboards.

3. Review of F1 Environmental Services (EVS) housekeeper job description indicated patient areas are to be cleaned daily, included but not limited to contact items such as phone, bedside table, over-bed table, empty trash, and mop floors.

4. Review of the housekeeping daily cleaning sheets lacked documentation the following patient rooms were cleaned daily as follows:
a. Rooms 211, 216, 218, 220, 222, 223, 224, 225, 226, and 227 lacked documentation that the rooms were cleaned on 12/17/24.
b. Rooms 207, 219, 220, 222, 223, 225, 226, and 227 lacked documentation that the rooms were cleaned on 12/18/24.
c. Rooms 205, 222, 223, 225, 226, and 227 lacked documentation that the rooms were cleaned on 12/19/24.
d. Rooms 222, 223, 225, 226, and 227 lacked documentation that the rooms were cleaned on 12/20/24.
e. Rooms 205, 218, 222, 223, 224, 225, 226, and 227 lacked documentation that the rooms were cleaned on 12/21/24.
f. Rooms 205, 217, 218, 220, 222, 223, 224, 225, 226, and 227 lacked documentation that the rooms were cleaned on 12/22/24.
g. Rooms 202, 220, 223, 224, 225, 226, and 227 lacked documentation that the rooms were cleaned on 12/23/24.
h. Rooms 202, 205, 218, 223, 224, 225, 226, and 227 lacked documentation that the rooms were cleaned on 12/24/24.
i. Rooms 202, 212, 213, 223, 224, 225, 226, and 227 lacked documentation that the rooms were cleaned on 12/25/24..

5. On 01/16/25 at approximately 3:40 p.m. this surveyor, accompanied by A1 (Director of Quality Management) and A10, was given a tour of the 200 unit. The patient rooms observed had trash on the floor, cluttered over-bed tables, an over-bed table that was peeling, a full bag of trash tied up to be removed sitting in the trash can, wet floor under the water container for the patients O2 and no wet floor sign, and a used urinal left on the over-bed table. In the nourishment room, the counter was wet under the ice machine. In the unoccupied patient rooms indicated ready for patient admissions, this surveyor observed a water leak in the bathroom, and a mattress cover that had a rip.