HospitalInspections.org

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to affect all patients served by the hospital.

Findings include:

Refer to Life Safety Code violations for findings.

Based on Medical Record (MR) reviews, review of policies and procedures and interviews with the facility staff, it was determined the facility failed to:

1. Obtain physician orders for 3 of 4 patients with PICC (Peripherally Inserted Central Catheter) lines. This affected MR #'s 2, 3 and 4.

2. Document specific flushing and dressing procedures provided to 3 of 4 patients with PICC lines. This affected MR #'s 2, 3 and 4.

3. Document specific wound care procedure for 2 of 4 patients with wounds. This affected MR # 2 and MR # 5.

This had the potential to affect all patients with PICC lines and wounds served by the facility.

Findings include:

Policy
Review Date: 4/2013

Midline and Peripherally Inserted Central Venous Catheters (PICC)

Documentation:
Maintenance: a. Document use of either heparinized saline or 9% saline flush on MAR (medication administration record).

Site Care/Dressing Change: 8. Clean around the insertion site with Chlorhexidine prep.


Policy
Review date: 8/20/13

Skin Assessment and Pressure Ulcer Prevention and Treatment Guidelines

Patient skin assessment should be completed by the RN/LPN (Registered Nurse/Licensed Practical Nurse) on admission and daily thereafter or as indicated by the patient condition. Once assessed, prevention and/or treatment should be implemented in a timely manner.


1. MR # 2 was admitted on 11/19/13 with diagnoses including Stage IV R (right) Ischial Decubitus Wound and Diabetes Mellitus.

A review of the physician orders dated 11/25/13 included, "Start Santyl ointment to R trochanter. Moisten kerlix with 1/4 Dakins Solution.." "Continue Polymem to areas on buttocks change every other day."

A review of the Skilled Nurse (SN) visit notes and MAR revealed documentation of wound care to the right trochanter on 11/29/13, 12/3/13, 12/4/13, 12/6/13 and 12/9/13. There was no documentation for the use of Santyl ointment and Dakins solution for the wound care to the R trochanter.

A review of the SN visit notes and MAR revealed documentation of wound care to the sacral/buttocks area on 12/3/13, 12/5/13 and 12/9/13. There was no documentation of Polymem dressing used for the wound care to the sacral/buttocks area.

A review of the SN visit notes and MAR revealed, from 11/29/13 to 12/9/13, documentation the PICC line was flushed. The SN failed to document what the PICC line was flushed with and the amount of flush used. The SN documented on the flow sheet that the site was cleansed and the dressing was changed. The SN failed to document what the site was cleansed with or what type of dressing was used.

Review of the physician's orders revealed there was no order written for PICC line care, PICC line flush, PICC line dressing change or the frequency care was to be provided.

An interview on 12/11/13 at 9:55 AM with Employee Identifier (EI) # 1, Chief Nursing Officer (CNO), confirmed the above findings.

2. MR # 3 was admitted on 12/6/13 with diagnoses including Post Operative wound (graft) infection and Peripheral Vascular Disease.

A review of the SN visit notes and MAR revealed, from 12/6/13 to 12/9/13, documentation the PICC line was flushed. The SN failed to document what the PICC line was flushed with and the amount of flush used. The SN documented on the flow sheet that the site was cleansed and the dressing was changed. The SN failed to document what the site was cleaned with or what type of dressing was used.

Review of the physician's orders revealed there was no order written for PICC line care, PICC line flush and PICC line dressing change and how often these were to be done.

An interview conducted on 12/11/13 at 10:05 AM with EI # 1, CNO, confirmed the above findings.



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3. MR # 4 was admitted to the facility on 12/4/13 with a diagnosis of Sacral Wound and Sepsis.

A review of the SN notes and MAR from 12/5/13 to 12/9/13, revealed documentation the PICC line was flushed. The SN failed to document what the PICC line was flushed with and the amount of flush used. The SN documented on the flow sheet the site was cleansed and the dressing was changed. The SN failed to document what the site was cleansed with or what type of dressing was used.

Review of the physician's orders revealed there was no order written for PICC line care, PICC line flush, PICC line dressing change or the frequency care was to be provided.

An interview conducted on 12/11/13 at 10:30 AM with EI # 1, Chief Nursing Officer, confirmed the aforementioned finding.




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4. MR # 5 was admitted to the facility on 10/22/13 with diagnoses including Left Heel, Sacrum and Lateral Left Foot Decubitus, Diabetes Mellitus and End Stage Renal Disease.

Review of the physician's orders dated 11/1/13 revealed orders for wound care to the sacral wound including, Santyl ointment, Calcium Alginate, piece of Comfeel, Mizpfoam tape every other day to keep stool out.

Review of the physician's orders dated 11/15/13 revealed orders for the wound:

1. Left heel - cleanse well with 1/4 Dakins Solution, apply wound gel, the saturate 1/2 kerlix with wound gel, pack well in wound to edge, cover with 4x4s and Kerlix BID (twice a day).

2. Left and right lateral feet- Santyl ointment, Polymem (small piece) tape daily.

Review of the wound care assessment dated 12/9/13 revealed the following wound care:

1. Left heel - Applied hydrogel 4x4's; kerlix tape. There was no documentation the wound was cleansed with 1/4 Dakins or packed with a saturated 1/2 Kerlix with wound gel, pack well in wound to edge, cover with 4x4s and Kerlix.

2. Lateral left foot - applied Santyl, 4x4, and kerlix wrap. There was no documentation of Polymem.

3. Sacrum - there was no documentation of wound care.

A review of the SN visit notes and MAR revealed documentation of wound care to the right trochanter on 12/1/13, 12/3/13, 12/4/13, 12/5/13, 12/6/13, 12/7/13, and 12/8/13. There was no specific documentation for the wound care provided.

An interview on 12/11/13 at 10:55 AM with EI # 1, confirmed the above findings.

Based on observations, review of the policies and procedures and interviews, it was determined the facility failed to ensure the staff followed their own policy for infection control. This had the potential to negatively affect all patients served by this facility.

Findings include:

Policy
Review date: 2/2013

General Departmental Infection Control Policy

II. Hand Hygiene
g. Decontaminate hands if moving from a contaminated body site to a clean body site during patient care.
i. Decontaminate hands after removing gloves.

G. Use of Gloves
4. When wearing gloves, change or remove gloves during patient care if moving from a contaminated body site to a clean body site within the same patient or to the environment.

1. An observation of wound care was conducted on 12/11/13 at 11:10 AM with Employee Identifier (EI) # 3. EI # 3 was observed to remove the old dressings from the sacral/buttocks areas, cleanse the areas with normal saline and apply clean dressings without changing gloves or hand hygiene. EI # 3 then removed the gloves and donned sterile gloves without hand hygiene prior to performing wound care to the right trochanter area.

An interview conducted on 12/12/13 at 9:00 AM with EI # 1, Chief Nursing Officer, confirmed the above.



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2. An observation of wound care was conducted on 12/11/13 at 8:25 AM with EI # 3 and EI # 4, Patient Care Technician. EI # 4 was observed to remove the old dressings from the left heel which had saturated dressing with sanguineous drainage. EI # 4 did not remove gloves and began assessing the patient's left eye with the same gloves used to remove the dressing from the left heel. EI # 4 assisted EI # 3 with all the wound care and continued wearing the same pair of gloves.

EI # 3 cleansed the left heel and left lateral foot with the same pair of gloves. EI # 3 removed the gloves and applied sterile gloves with out hand hygiene.

EI # 3 removed the dressing the the right lateral heel with the same gloves used to dress the left heel and foot. EI # 3 then changed gloves without hand hygiene.

EI # 3 and EI # 4 turned the patient to the left side. There was stool in the patient's diaper and EI # 3 cleaned the stool off the patient. EI # 3 used the same pair of gloves used to clean the stool to remove the dressing from the patient's sacrum.

An interview conducted on 12/12/13 at 9:00 AM with EI # 1 confirmed the staff did not follow the hospital policy.