HospitalInspections.org

Based on review of facility documentation, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure the documentation of accurate and concise nursing records and reports which reflect the progress of the patient and contribute to the continuity of patient care for one of one medical record reviewed (MR1).

Findings include:

A review of facility documentation revealed "Nursing Assessment, Daily, Revision Nov 2016...Purpose: To ensure a Registered Nurse (RN) assesses the patient's need for nursing care and plans, implements and evaluates that care...Procedure: A. Assessment and Reassessment: 1. Initiated upon patient arrival, the initial admission assessment is to be completed within twenty-four hours. The Registered Nurse will be responsible for performing the admission physical assessment, subsequent physical reassessment at least once daily..."

The review of MR1 and MR2 Physician Progress Note revealed documentation that the patient was admitted with a rash on the entire body at both admissions.

The review of MR1 and MR2 nursing documentation revealed no documentation of the patient's rash on admission or throughout the admissions.

An interview conducted on June 29, 2017 at 1:30 PM with EMP3 confirmed that the MR1 and MR2 did not contain nursing documentation documentation of the patient having any rash on admission or during the stay at the facility. Further interview confirmed that the physician's documentation did have documentation that the patient was admitted with a rash on the entire body at both admissions.

Based on review of facility documents, observation and staff interview (EMP), it was determined the facility failed to ensure staff performed hand hygiene prior to donning gloves and failed to properly store soiled linen.

Findings include:

1. A review on June 29, 2017, of facility policy "Hand Hygiene" last reviewed October 2016, revealed, "...Procedure A. Indications for hand washing and hand antisepsis: ...3. Decontaminated hands before having direct contact with patients...8. Decontaminate hands after contact with inanimate objects (including medical equipment) in the vicinity of the patient.

Observations on June 29, 2017, at 10:10 am revealed EMP6 put on gloves and gown to go into a patient room. EMP6 did not perform hand hygiene prior to donning the gloves and gown.

Observations on June 29, 2017, at 10:15 am revealed EMP7 put on gloves and gown to go into a patient room. EMP7 did not perform hand hygiene prior to donning the gloves and gown. After placing gloves, EMP7 continued to pick up a chart, move it, and then close a door on a wall mounted cabinet. EMP7 then picked up a medication and entered the room.

Observations on June 29, 2017, at 10:45 am revealed EMP8 was several doors down, when another employee asked EMP8 for assistance. EMP8 walked to the room, donned gloves and gown, but did not perform hand hygiene prior to placing the gloves.

EMP3 accompanied the tour, and confirmed the employees did not perform hand hygiene prior to donning the gloves.

2. A review on June 29, 2017, of facility policy "Environmental Services-Linen" last reviewed March 2015, revealed "E. Soiled linen Collection... 2. Soiled linen will be transported in covered carts..." The policy did not address the storage outside of soiled linen.

Observation on June 29, 2017, at 10:40 am, outside the building, revealed three plastic laundry carts. The carts did not have any doors or covering. Each cart contained several bags of soiled linen. The carts were stored outside, accessible, and not under any type of roof cover.

An interview conducted on June 29, 2017, at 10:40 am with EMP3 confirmed the carts contained bags of soiled linen and were stored outside with no protection.