HospitalInspections.org

Based on record review, interview, and policy review, facility staff failed to:
-Provide information about advance directives when information had been requested for four (#2, #13, #17 and #20) of 11 patients reviewed;
-Produce a copy of advance directives when it was documented that patient had advance directives in the chart for one (#15) of one patients reviewed with a current advance directive;
-Obtain copies of advance directives for four (Patient #1, #14, #19 and # 22) of four patients reviewed that was documented the patient had a current advance directive;
-Document whether a patient did or did not have an Advance Directive for four (#10, #11, #18 and #23) of four patient records reviewed without documenting the presence or absence of an Advance Directive.
These failures occurred on 13 of 17 patient records reviewed for these issues but had the potential to affect all patients admitted to the facility. The facility census was 23.

Findings included:

1. Review of facility policy RI 1240 dated May 2009, titled, "Advance Directives" gave direction for staff:
- to ask all adult patients, on admission, if they have an Advanced Directive for Health Care and/or a Durable Power of Attorney for Health Care (DPOA);
- if the patient states that they have either of these documents they will be reminded that it is their responsibility to have someone bring a copy into the hospital within 24 hours. The copy should be placed in the patients' file;
-if the patient does not have advanced directives but expresses a desire for additional information the Chaplain will be contacted for referral and follow up;
-the Chaplain will note in the patients' chart when they assisted a patient in completion of an advance directive.

Review of facility document titled, "Statement of Patient Rights and Responsibilities", dated October 2007, showed patients have the right, "To formulate advance directives or directives to physicians regarding the type of care desired in the event you become incapable of communicating those desires including the right to become an organ donor, in the event the patient qualifies".

2. Review of current Patient #13's "Advanced Directive Acknowledgement Form", completed on 01/04/12, showed:
-patient did not have advance directive for healthcare or durable power of attorney for healthcare;
-patient would like to receive information or complete an advance directive or durable power of attorney for healthcare;
-there was no documentation that the Chaplain was contacted.

Review of Spiritual Care Progress notes showed:
- Staff CC, Chaplain visited the paitent on 01/05/12 but Staff CC did not document that advance directive information was discussed.
-Staff CC visited the patient on 01/13/12 but Staff CC did not document that advance directive information was discussed.

During an interview on 01/24/12 at 10:15 AM Patient #13's family member stated that they were asked about advance directives on admission and they indicated they would like information. The family member stated they were very confused about advance directive and durable power of attorney. Family member stated that they did not receive any information but they were still interested. Patient #13 confirmed family member's comments.

During an interview on 01/24/12 at 3:30 PM Staff O, Charge Nurse, stated that normally a request for information about advance directive would generate a call to the Chaplain and the nurse would document date and time call was made. Staff O stated that she was not sure why that didn't happen in this case. Staff O stated that the nurse would not typically follow up on advance directives unless the family made the nurse aware that they had not received the information.

During an interview on 01/25/12 at 4:50 PM Staff CC, Chaplain, stated that if a patient requests information about advance directives the nurse calls and leaves a message on his phone. Staff CC stated that he would usually take information to the patient within 72 hours. If the patient is not alert he would leave the packet and make a point to follow up with the family on the next visit. Staff CC stated that he visits every patient once a week and documents discussion about advance directives.

Record review on 01/24/12 of current Patient #2's medical record showed the patient did not have an Advance Directive in place upon admission on 01/10/12, but requested to receive information to complete an Advance Directive at that time. A spiritual care progress note dated 01/11/12 showed that the Chaplain visited the patient, who was alone, and documented that communication with the patient was difficult and that information on Advance Directives was left for the family. There was no indication in the medical record that further follow-up with the patient or family occurred to formulate the Advance Directive.

Record review of Patient #17's medical record showed the patient was admitted on 12/16/11 with a diagnosis of Acute Respiratory Failure. Review of the "Advanced Directive Acknowledgement Form" showed the patient requested more information regarding advanced directives. Staff CC, Chaplain, documented in the medical record on 01/21/11 and 01/20/12 but did not document any discussions on advanced directives. Staff D, RN, Case Manager, documented in the medical record on the dates of 01/02/12; 01/15/12; 01/09/12; 01/16/12; 01/18/12 and 01/23/12 but without mention in the documentation of advanced directives.

Record review of Patient #20's medical record showed the patient was admitted on 01/09/12 with a diagnosis of Acute Respiratory Failure. The patient completed the "Advanced Directive Acknowledgement Form" and had no Advanced Directive and no DPOA but requested more information on 01/10/12. Documentation on 01/11/12 by Staff CC, Chaplain showed he left information on the Advanced Directive with the patient. No further documentation regarding an Advanced Directive was in the medical record.

3. Review of current Patient # 15's medical record showed:
- "Advanced Directive Acknowledgement Form", completed on 12/30/11 at 4:15 PM, indicated patient had an advanced directive for healthcare and durable power of attorney for healthcare and that copies of these documents were on the chart. There were no copies of advanced directive or durable power of attorney for healthcare in the patients' medical record.

-"Spiritual Care Progress note" showed Staff CC, Chaplain visited the patient on 01/05/12, 01/10/12 and 01/19/12. Staff CC did not document any discussion of advanced directives.

During an interview on 01/24/12 at 3:15 PM Staff N, Registered Nurse, confirmed that no advanced directive was in the chart and that normally if a patient had an advance directive they would be in the chart.

During an interview on 01/24/12 at 3:50 PM, Staff Z, Registered Nurse (RN) stated that she was involved in the admission of Patient #15. Staff Z stated that she did not ask the patient if he had an advanced directive but believed the patient was given the Advanced Directive Acknowledgement form to complete and the patient probably indicated on the form that a copy of the advanced directive was on the chart. Staff Z stated that she did not review the admission paperwork when she placed it in the medical record.

4. Record review on 01/24/12 of current Patient #1's medical record showed the patient had an Advance Directive in place upon admission on 01/06/12, but it was not located in the record. A copy of the Advance Directive was documented as requested on 01/06/12, but the record did not indicate further follow-up to obtain the Advance Directive.

Review of Patient # 14's medical record showed "Advanced Directive Acknowledgement Form", completed on 01/05/12 at 12:55 PM, indicated patient had advanced directive for healthcare and that a copy of this document was not on the chart "because the patient said they were not able to obtain them".

Review of Patient # 22's medical record showed "Advanced Directive Acknowledgement Form", completed on 01/12/12, untimed, indicated patient had advanced directive and durable power of attorney for healthcare. The question about "copies on chart" was followed by two hand written question marks. The form was signed by the patients' wife. The admission nurse did not sign the form indicating that the information was reviewed with the patient or family member.

During an interview on 01/24/12 at 3:30 PM Staff O, charge nurse, stated that staff should have further explored and documented information regarding the advanced directives for Patient #14 and Patient #22.

Record review of Patient #19's medical record showed the patient was admitted on 01/20/12 with a diagnosis of Acute Respiratory Failure. The patient was listed as a Full Code with a current Advanced directive and a Designated Power of Attorney (DPOA) on the "Advanced Directive Acknowledgement Form". There was no copy of the patient's Advance Directive in the chart but it had been documented as requested on 01/20/12 by Staff D, RN, Case Manager. The record contained no documentation by Staff CC, Chaplain. Staff D documented in the medical record on the dates of 01/23/12 and 01/24/12 but did not mention follow up for the Advanced Directive.

5. Record review on 01/26/12 of current Patient #23's medical record showed no documentation that the patient was questioned if he had an Advance Directive in place upon admission on 02/16/11. There was no Advance Directive in the record and no documentation that the facility followed up to offer education or assistance to formulate an Advance Directive.




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Record review of Patient #10's medical record showed the patient had been admitted on 12/23/11 with a diagnosis of wound debridement for an injury. The record contained one note documented by Staff CC, Chaplain, on 01/02/12 but no documentation regarding an advance directive. The record contained no "Advanced Directive Acknowledgement Form", and no social worker or case management notes were documented in the medical record.

Record review of Patient #11's medical record showed the 83 year old patient had been admitted on 01/13/12 with a diagnosis of Acute Respiratory Failure. The medical record did not contain an advance directive and no documentation from Staff CC, Chaplain.

During an interview with Patient #11's adult child on 01/23/12 at 2:55 PM, the adult child stated that no one had discussed an Advance Directive with them but they would like more information.

Record review of Patient #18's medical record showed the patient had been admitted on 01/20/12 with a diagnosis of Acute Respiratory Failure. The medical record did not contain the "Advanced Directive Acknowledgement Form" and there was no Advance Directive in the medical record and no documentation by Staff CC, Chaplain.

6. During an interview on 01/26/12 at 12:00 PM Staff J, Director of Quality, stated that he believes that sometimes the nurse thinks the Chaplain is following up and the Chaplain thinks the nurse is following up. Staff J stated that the facility recognized it has problems in the advance directive area but had not yet taken steps to correct the process.

During an interview with Staff B, Chief Nursing Officer stated that follow-up to Advance Directives was an issue and that there was no follow-up to obtain a patient's Advanced Directive after the initial contact by the Chaplain.






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Based on observation, interview, and policy review the facility:
- failed to ensure staff followed contact isolation precautions for six (#13, #15, #17, #19, #28 and #29) of six patients identified as being on isolation precautions. (Patients identified as having a particular organism especially contagious or difficult to treat.) Failure to follow contact isolation precautions potentially results in cross contamination of infectious organisms and could impact all patients in the facility.
- failed to take measures to prevent the potential spread of infection when staff handled clean patient items with contaminated gloves and did not perform hand hygiene and failed to properly dispose of a contaminated object, used during a patient procedure, from one (Patient #2) of one patient room. The facility census was 23.

Findings included:

1. Record review of the facility policy IC.716 titled, "Transmission Based Precautions" revised 03/09/11 showed direction for facility staff to ensure Contact Precautions are utilized by washing hands, wearing gloves and wearing a clean, non sterile gown when entering the contact isolation room. Further direction showed that staff should remove the gown before leaving the patients' environment, after gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patients or environments.

2. Review of facility document titled, "Isolation Census" dated January 24, 2012 showed Patient #13 was on contact isolation for VRE (Vancomycin Resistant Enterococcus- an organism that causes infection and is very resistant to powerful antibiotics, medication used to fight infections).

Observation on 01/24/12 at 12:01 PM showed Staff T, CNA, entered Patient # 13's room without donning Personal Protective Equipment (PPE, gown and gloves) spoke with patient and family member for about 30 seconds, exited room, then donned PPE and reentered the room. An "Isolation" sign was posted on the door.

3. Observation on 01/23/12 at 2:10 PM, showed Staff X, RN stand in Patient #19's contact isolation room without gloves on and with a yellow gown (used for contact precautions to prevent contaminating clothes and skin) partially pulled up on his arms, but the gown did not cover his shoulders and was not tied at the back of the neck or around the waist.

During an interview on 01/23/12 at 2:12 PM, Staff X stated that Patient #19 was on contact precautions for VRE and that gloves and a contact precaution gown should be put on and tied around the neck and waist prior to entering a patient's room.

During an interview on 01/26/12 at 9:45 AM, Staff C, Infection Control Nurse, stated that staff should put on gloves and a gown for contact isolation patients, prior to entering the patient's room. Staff C added that the gowns should be tied at the back of the neck and waist at all times.

4. Review of facility document titled, "Isolation Census" dated January 24, 2012 showed Patient #15 was on contact isolation for VRE.

Observation on 01/24/12 at 12:05 PM showed Staff Y, CNA, performed a finger stick (blood sugar check) on Patient #15. Staff Y did not have on gown while in room. Room did have "Isolation" sign posted on door.

Observation on 01/24/12 at 12:07 PM Showed Staff T, CNA, took meal tray into Patient #15's room without donning PPE. Staff T was in room about one minute getting over bed table in place and removing dish covers. When Staff T exited room, Staff P, LPN (Licensed Practical Nurse) commented to Staff T that she did not have a gown on. Staff T responded, "So?" Room did have "Isolation" sign posted on door.

During an interview on 01/25/12 at 10:15 AM Staff T, CNA, was asked about her "So?" comment to Staff P, LPN, when she exited a patient's room yesterday without a gown and gloves on. Staff T stated that she was surprised by Staff P's comment because no one had ever told her it was necessary to put on a gown and gloves when passing meal trays to patients' that are on isolation precautions. Staff T stated that she always passed meal trays without putting on a gown and gloves.

During an interview on 01/25/12 at 1:15 PM, Staff C, Clinical Outcomes Manager, stated that it is her expectation that all staff utilize PPE when entering a room where a patient is on isolation precautions per policy. Staff C stated that there has been a lot of coworker turnover and reeducation of staff.





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5. Observation on 01/23/12 at 3:17 PM showed Staff K, PCT (Patient Care Technician), exiting the room of Patient #17 who was on contact isolation for VRE. Staff K exited the room with PPE still in place and began tearing off the PPE gown as she walked around the nurses' station and disposed of the gown in the trash can behind the nurses' station, approximately 24 feet.

During an interview on 01/23/12 at 3:20 PM Staff K stated she did not know what organism caused Patient #17 to be on contact precautions. Staff K said that she should have removed the gown and disposed of it before leaving the patient's room.

During an interview on 01/23/12 at 3:25 PM Staff EE, MSN (Master of Science in Nursing), RN, Executive Director of Nursing, Nursing Logistics, stated she did see the PCT leave the room with the PPE still on and walk behind the nurses' station to dispose of the gown. Staff EE stated that was not procedure for contact isolation PPE.

6. Observation on 01/24/12 at 12:04 PM during the noon meal pass showed Staff M, RN, exit the room of Patient #28 who was on contact isolation for VRE. Staff M walked across the hall to a wooden cabinet marked "staff only" and removed two drinking straws then went back into the patient's room. Staff M did not remove her PPE upon exiting the room or change it upon reentering the patient's room.

7. Observation on 01/24/12 at 12:04 PM during the noon meal pass showed Staff L, RN, in the contact isolation room of Patient #29. Staff L did not have PPE on while in the patient's room.

During an interview on 01/25/12 at 9:55 AM Staff O, RN, Charge Nurse/Nursing Supervisor, stated that the nurses and techs (Patient Care Technicians) should remove their PPE before they leave a contact isolation room and should donn PPE before entering a contact isolation room - no matter what the circumstances. Staff O stated she would try to monitor more closely and stated that they (nurses and PCT's) have been educated many times on proper PPE procedures.

8. Observation on 01/24/12 at 9:25 AM showed Staff DD, Housekeeper with gloves on, cleaning Patient #2's toilet rim with a paper towel. Staff DD then:
-exited the room with the contaminated gloves still on and removed a key from her pocket;
-unlocked a cabinet and removed a clean pack of bundled paper towels with the contaminated gloves still on;
-re-entered Patient #2's room and used keys to unlock the paper towel dispenser with the contaminated gloves still on;
-placed the bundled paper towels in the dispenser, with the contaminated gloves still on.
Staff DD then left Patient #2's room and picked up two "Wet Floor" signs with the contaminated gloves still on, and rested them against a wall in the hallway.

During an interview on 01/26/12 at 10:00 AM, Staff DD stated that she should have changed her gloves and washed her hands after cleaning Patient #2's toilet and after she left the room. Staff DD added that "we are supposed to work from clean to dirty", indicating that the paper towels should have been replaced first and then cleaned the toilet.

During an interview on 01/26/12 at 10:45 AM, Staff C, Infection Control Nurse, stated that housekeeping staff are contracted staff and that the only infection control training they received from the facility was how to clean the patient monitors (screens which monitor vital signs).

Observation on 01/24/12 at 9:35 AM showed a guide wire (a thin wire used in patient procedures) projecting approximately two inches beyond the top of an enclosed sharps box (container where used needles, used syringes, and used sharp objects are placed) in Patient #2's room. The sharps box was located on a entry wall of the patient's room where staff or visitors could brush against the contaminated wires projecting from the sharps container, contaminating their clothes or skin. When the projecting wire was shown to Staff FF, RN, she left the guide wire projecting out of the sharps box.

During an interview on 01/24/12 at 9:45 AM, Staff FF, RN, stated the wire was from a Dobhoff (a tube placed through the opening of the nose and advanced through the throat and into the stomach to administer nutrition and medications) which was placed in Patient #2 "a couple of days ago".







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