HospitalInspections.org

Based on medical record review, care plan review, document review, and staff interview, the facility failed to ensure the nursing staff developed, updated and kept current an appropriate nursing care plan for Patient #1, one (1) of two (2) patients reviewed, to include the diagnosis of Methicillin-resistant Staphylococcus aureus (MRSA), treatment with Vancomycin, and Isolation Precautions.

Findings include:

Cross Refer to A397 for the facility's failure to ensure the development and update of an appropriate nursing care plan to include the diagnosis of MRSA, treatment with Vancomycin, and Isolation Precautions for Patient #1.

Based on medical record review, document review, policy review, family interview, and staff interview, the facility failed to ensure Patient #1, one (1) of two (2) patients reviewed, had a nursing care plan in place regarding the need for Isolation Precautions related to the diagnosis of Methicillin-resistant Staphylococcus aureus (MRSA) and treatment with Vancomycin; and failed to ensure the patient's family was informed of the need for Isolation Precautions and why.

Findings Include:

The State Office received a complaint from Patient #1's family regarding the quality of care Patient #1 received while a patient at Hospital #1 from 2/26/16 to 4/1/16. The complaint stated Patient #1 was admitted to the facility from Hospital #2, after amputation of a toe on his right foot, for IV (intravenous) antibiotics, wound care, and therapy. (Record review showed it was his left foot) His diagnoses were Dementia and Diabetes. The family's complaint included the staff's lack of concern when their father's IV infiltrated; whether or not his Diabetic dietary needs were met; the staff's lack of concern regarding his high blood glucose readings while there; whether a foley catheter was medically necessary, the lack of care the catheter received while he had it and the Urinary Tract Infection he got from having the catheter; the limited physical therapy he received; the staff's failure to inform the family why Isolation Precaution signs were placed on his door; why the staff/physician stated Patient #1's MRSA (Methicillin-Resistant Staphylococcus Aureus) was cleared and discharged him to a nursing home when it was not cleared.

On 6/15/16 at 10:00 a.m. an unannounced visit was made to Hospital #1. An entrance conference was held with the Director of Nurses (DON) and the CEO to discuss the reason for the visit.
Review of Hospital #1's medical record for Patient # 1 revealed:
He was admitted via ambulance from Hospital #2 on 2/26/16 by Physician #1 with Leukocytosis and Severe Malnutrition. A dressing was intact to left foot due to status post amputation x2 weeks of left great toe due to gangrene. In the past he had amputation of the left second toe. Other diagnoses included Infected Left Great Toe, Possible Osteomyelitis in left foot area, Diabetes Type 2, Anemia, Hypertension, blind in left eye, and Peripheral Vascular Disease. Physician's orders included Rocephin two (2) grams IV (intravenous) q (every) 24 hours. Physical Therapy, Occupational Therapy and Speech Therapy Screenings. Social Services was ordered for evaluation and to begin Discharge Planning. He was placed on a Mechanical Soft, Consistent Carbohydrate/1800 Calorie Diabetic Diet; Megace 200 mg (milligram) before meals. His orders included Intake and Output (I&O) every shift, bedrest, fall precautions, accuchecks AC/HS (before meals and at hour of sleep) with low dose Novolog Sliding Scale (There was no documented evidence of a physician's order for blood glucose parameters to be reported to him (too high or too low - his blood sugar on admission was 190) and multiple laboratory (lab) studies were ordered which included septic workup, blood cultures, urine culture and wound culture. Physician #1's wound care orders included: Cleanse left foot with wound cleanser/Normal Saline, apply Santyl Cream, and apply Wet to Dry dressing. Change daily.
A 2/26/16 wound culture of left great toe incision cite showed positive for Enterobacter cloacae. Rocephin 2 grams IV (Intravenous) Q (every) 24 hours was started.
2/28/16 Urine culture of 2/26/16 was negative. Cipro IV Q 24 hours was started.
2/29/16 Registered Dietician's (RD) consult revealed: Oral intake < (less than) 75%; Prostat one pkt (packet) BID (twice a day) was ordered; Physical Therapy was ordered for 3-5 times a week. Glucotrol XL was started for mildly elevated blood sugar. Physician's progress note documented patient's biopsy was positive for osteomyelitis. He was given an increased dose of Megace for poor appetite.
3/2/16 His Rocephin was d/c'd because wound cultures were not susceptible. Remained on Cipro.
3/8/16 Physician #1 documented wound healing and BS doing fairly well.
3/9/16 Physician #1 documented that the patient's BS was reasonably good recently.
3/10/16 Physician #1 documented BS running a little high lately.
3/11/16 Physician #2 documented that the patient's plan of care was discussed with family.
3/14/16 Physician #1 documented patient is able to walk a little, but gets tired and weak. Stated, "I think it is possible he may not return to his premorbid status because of his Alzheimer type Dementia...If he does reasonably okay he should be discharged as soon as Friday, but I do not know if he is ready to go to the house because he is not as functional as he used to be."
3/15/16 "D/C Foley Catheter; Bedside Commode; Discharge planning for Friday". Nursing Home placement was discussed with family by Physician #1. They were told that Social Services would help them with this. Physician #2 documented lab work glucose 130 and that the left great toe needed further debridement.
3/16/16 at 4:18 p.m. the Physician's Progress note documented that Patient #1 failed to void after midnight. His foley was reinserted and bladder training was started.
3/17/16 Physician #1's Progress Note stated that the foley catheter was still in place due to the patient being unable to void when it was removed. Discharge for 3/18/16 cancelled. Social Services to talk with family about nursing home placement. The patient's left great toe area was debrided by Physician #2. A dry dressing was started.
3/18/16 Blood and Urine Cultures were done due to patient having an elevated white blood count of 19.2. Cultures were positive for MRSA. [any of several bacterial strains of the genus Staphylococcus aureus that are resistant to beta-lactam antibiotics (as methicillin and nafcillin) and that are typically benign colonizers of the skin and mucous membranes (as of the nostrils) but may cause severe infections (as by entrance through a surgical wound) especially in immunocompromised individuals]
3/19/16 Physician #2 was notified of positive blood cultures for Staphylococcus Coagulase-negative. He ordered Vancomycin 1gm (gram) STAT (immediately) IV and then daily with pharmacy to monitor levels and adjust dosages. There was no documented evidence that Patient #1's nursing Care Plan was ever updated to include the Vancomycin treatment or that any Isolation Precautions were ordered or put in place due to the diagnosis of MRSA for Patient #1. Physician #2 documented patient was eating an average of 50% of meal, leukocytosis with elevation of WBC counts, elevation in neutrophil count, elevated BUN, and BS ranged from 144 to 170.
3/21/16 Physician #1 documented the positive blood culture for MRSA and that the culture had been taken because the patient had an elevated white count. Stated patient would probably be in hospital for two more weeks and family had decided to put him in skilled care at discharge.
3/22/16 blood cultures X2 were negative. A weekly sedimentation rate was ordered to monitor his sepsis.
3/23/16 Physician #1 ordered to discontinue Foley catheter per family request because they have decided to take the patient home. At 10:35 a.m. foley catheter was discontinued. At 6:00 p.m. patient had not urinated. Daughter refused to let nurse reinsert foley. At 7:00 p.m. diaper continued to be dry. Patient's intake for 3/23/16 was 1800 cc. Output was 300 cc plus one (1) diaper.
3/24/16 Physician #1 Progress note documented "I discussed the staph infection with the patient's caregiver...(Physician #2) wants him to stay here until his sepsis is treated." At 7:45 p.m. patient's abdomen was documented as distended. Physician was notified. At 9:00 p.m. patient's foley catheter was reinserted due to urinary retention.
3/29/16 RD Consult on 3/29/16: Oral intake < 75%. Sugar-free Mighty Shake one box BID was added.
3/31/16 Physician #2 documented lab blood glucose was 215. Vancomycin and Cipro both continued. At 3:20 p.m. Physician #1 wrote orders for Patient #1 to be discharged on 4/1/16 to Nursing Home #1 which included: PT eval and treat; 1800 calorie diabetic mechanical soft, consistent carbohydrate diet - assist with meals; Accuchecks AC & HS; low dose Novolog insulin sliding scale: BG (blood glucose) 70-130 0 units (U); 131-180 2U; 181-240 4U; 241-300 6U; 301-350 8U; 351-400 10U; > (greater than) 400 12U and call MD. Cleanse wound to left foot with normal saline and apply dry dressing. Foley care daily and prn (as needed). Medications ordered included Vancomycin 1 gm IVPB (Intravenous Piggyback) daily X14 days. Another order signed by Physician #1 on 3/31/16 at 6:40 p.m. included: Keep Vanc (Vancomycin) level between 10-20. Vanc level weekly. CBC, BUN, Creatinine, ALT, Total Bilirubin level weekly.
Review of a 4/1/16 Discharge Summary dictated and signed by Physician #1 revealed: Discharge Diagnosis: Osteomyelitis of enterobacter cloacae in left foot great toe incision; Peripheral Vascular Disease; malnutrition; Anemia; Hypertension; MRSA Sepsis; and Alzheimer's type Dementia, moderate. "Summary of Hospital Course: This 88 year old African American male was sent over here after having infection in his right great toe with enterobacter cloacae that was osteomylitis. He developed an infection in the wound site and was sent here. He was treated for this...initially improved. His infection seemed to clear up and his wound was getting smaller. However, when it was thought he might be discharged he started running a fever. Blood cultured at that time showed MRSA... placed on Vancomycin. Was lethargic during this time. He did improve after several days on Vancomycin and got back to his therapy. He was sent to (Nursing Home #1)...is on Vancomycin for two more weeks IV...He will follow up with a doctor at the nursing home..."

4/1/16 11:00 a.m. Patient was discharged to nursing home via wheelchair at 12:30 p.m. with foley catheter intact.

On 6/15/16 at 12:00 noon a telephone interview was held with Registered Nurse (RN) #1. RN #1 was the nurse in charge of Patient #1 when the physician ordered the Vancomycin to be started. RN #1 stated that she could not remember if she informed the family about the need for isolation precautions to be observed while they were present in the room the day isolation was started for MRSA, 3/22/16. She also stated, "We use to have an Isolation Precaution Form that we would fill out and have a family member sign and put it in the chart, but I think we stopped doing that a while ago."

On 6/15/16 at 3:20 p.m. an interview with Licensed Practical Nurse (LPN) #1 revealed that RNs usually are the ones who explain Isolation Precautions to patients and families.

Review of the facility document "Isolation Precautions" revealed: "You have been placed on..... isolation precautions. Patients are placed on isolation precautions to prevent spread of infection. What does this mean? You will either be in a provide room or share a room with someone who also has the same infection ... " This document goes on the say what staff and visitors must do to ensure not to spread the infection to other patients and visitors.

Review of an isolation sign the DON stated was placed on the patient's door revealed: "STOP All visitors must check with nurse before entering! CONTACT ISOLATION To enter room you must wear: Gown Gloves Dispose of these items in room before exiting! Keep Door Closed!"

On 6/15/16 at 4:30 p.m., after reviewing Patient #1's medical record, the DON failed to be able to provide any documented evidence indicating that Isolation Precautions were observed during Patient #1's hospital stay. The DON also stated that there was no documented evidence that the patient's Plan of Care was changed at that time to reflect the diagnosis of MRSA, treatment with Vancomycin and the necessity of Isolation Precautions.

On 6/15/16 at 5:00 p.m. an exit conference was held with the DON. No additional documentation was submitted for review.

Review of the facility's "Isolation Processes" policy (Date of Revision 08/15) revealed: "Policy: (Hospital) strives to reduce the risk of infections to patients, healthcare workers, and visitors... Purpose: To ensure quality management of infection control within the facility structure... Procedure: ... Infection Control Nurse will work jointly with the host hospital Infection Control Coordinator. Patient/Family education regarding infection control issues will be provided by (hospital) staff. Quality Improvement monitoring of infection control management will be performed by (hospital) staff. (Hospital) staff will provide isolation precaution for those patients admitted to (Hospital). (Hospital) clinical staff will utilize (Hospital) Infection Control Manual for management of isolation processes. Patients will be admitted to a hospital isolation room... when necessary. Implementation: a. In the event that a physician cannot be reached, the Infection Control Nurse or Director of Clinical Services of (hospital) may implement isolation procedures... f. Isolation guidelines are summarized on the (hospital) Infection Control flipchart located in the nurse ' s station for those providing direct or indirect patient care. ... Cleaning of Room: a. ...nursing staff will notify the Host Hospital Building Services of any rooms occupied for isolation care management. Host Hospital Building Services will perform daily room cleaning according to the host hospital policies and procedures.... Quality Monitoring - a. Infection Control Nurse will be responsible for monitoring patients on isolation. Patient board will be updated daily as need to place in isolationor take off isolation changes."

Review of the facility's "Care Of The Diabetic Patient" policy (Revision Date 08/15) revealed: "Policy - (Hospital) will provide care to patients diagnosed with diabetes with the goals of assisting to maintain their blood sugar levels within therapeutic ranges; decreasing complications related to diabetes and understanding how the disease may affect their recovery. Purpose: To establish guidelines for care of the diabetic patient. To delineate who is responsible for components of care of the diabetic patient. Procedure: ... 4) Blood sugar checks will be accomplished by staff per physician orders. RNs and LPNs will be expected to do glucometer checks as ordered. CNAs may become certified to do glucometer checks... 5) All glucometer readings will be documented in the patient chart. 6) Glucometer readings will be utilized to follow orders as received by the physician. Parameters for reporting results (i.e.: values above or below specific readings) should be identified on the patient's order sheet.... "

On 7/12/16 from 3:40 p.m. to 4:45 p.m. telephone interviews were held with three of Patient #1's daughters. All three daughters stated that they were never told why the Isolation Precaution signs were on their father's door, why the gowns and masks were outside the door, or what they were suppose to do with them. "They just appeared one day." One daughter stated that a few days after the items appeared she Googled MRSA. "It scared us to death. We did not know, and they (hospital staff) never told us, that MRSA is contagious. We thought it was just a Staph infection." The daughters also stated that they asked staff constantly not to bring their father so many starches with his meals because he was a diabetic and would not eat them. "Every meal had potatoes or rice and green beans. He wanted more vegetables. We asked to talk to the Dietician, but we were told we couldn't because she was at the main hospital." All three daughters were concerned that their father's blood glucose ran high while in the hospital and staff never seemed concerned about it. They stated they were aware the nurses were suppose to do Accuchecks. They did not know how often Accuchecks were ordered to be done, but they did state that the nurses did not do Accuchecks before every meal. The daughters stated that they contacted and spoke with the hospital's Patient Advocate. The Patient Advocate told them she would look into their concerns and get back to them, but she never did. The daughters also stated concern that they were told their father's infection was cleared up before he was discharged to the nursing home. But once at the nursing home they found out that their father still had MRSA and was still getting antibiotics via IV. One daughter stated, "We feel like overall there was a big lack of communication and we are still upset with the poor care we feel our father received while a patient there."


On 7/13/16 at 2:10 p.m. a telephone interview was held with the DON. When asked why the facility had stopped using the Isolation Precaution Form she stated that they had not stopped using it. "It is part of our admission packet. We just never knew we should get the patient or family to sign it.... When (Patient #1) was placed on Isolation Precautions we explained to his daughters what it meant and why he was on it. He also had an Infectious Disease Physician (Physician #2) that saw him and kept the family informed." She stated that there is no form to notify Housekeeping that a patient is in isolation, "We place a big isolation sign on the door and the gowns and masks are right at the door. This signifies to housekeeping that they need to observe isolation precautions when they are cleaning the room." When asked about this patient's diet and the family's dissatisfaction with what he received to eat the DON stated, "The patient or the family is given a menu daily to pick out what the patient wants to eat the next day. So whatever he got to eat was what they or he picked out for him to eat. Most all hospitals do it that way." She also stated that the family never made complaints to the staff about the meals and could not remember them asking to see or talk to the Dietician.

7/14/16 at 1:45 p.m. the hospital's Infection Control Nurse was interviewed via telephone. She stated that she is also the hospital's Quality Assurance Nurse. When asked how, as their Infection Control Nurse/QA Nurse, she learns of any new infections she stated that she learns about every infection in their Daily Review. "I knew that he (Patient #1) had MRSA the day he was diagnosed." She stated that she documents and tracks every infection until it is either resolved or the patient is discharged. "Normal hospital policy is to place every new admission on Contact Precautions for 72 hours just to make sure there is no infection or what type of infection we are dealing with."

Review of Patient #1's Medication Administration Records from admission on 2/26/16 to discharge on 4/1/16 revealed physician's orders regarding accuchecks four times a day were followed/documented. Review of Patient #1's medical record revealed no documented evidence he developed a Urinary Tract Infection during his hospital stay.


Review of Patient #1's Care Plan from 2/26/16 to 4/1/16 revealed no documented evidence of an appropriate care plan with updates, reassessments, response to nursing interventions, and revisions as needed regarding the diagnosis of MRSA, treatment with Vancomycin and Isolation Precautions. Medical record review revealed there was no documented evidence that the facility's staff observed Isolation Precautions from the time that MRSA was diagnosed and Vancomycin was ordered on 3/19/16 until the patient was discharged on 4/1/16. Medical record review and policy review revealed the facility followed their policies and procedures concerning wound care, diabetic care, dietary needs, urinary retention/foley care and therapies received. All physician's orders were followed.