HospitalInspections.org

Based on observation, interview and record review the facility failed to prevent the development of a Stage II pressure sore (partial thickness skin loss, usually appearing as a blister, or shallow crater) for one of four patients reviewed with pressure sores (Patient #5) and failed to prevent the worsening of existing pressure sores on two of two patients (Patient #9 and #10) when the staff did not follow the physicians orders to turn the patients. The facility also failed to prevent weight loss for Patient #5, by failing to document the consumption of an ordered liquid nutritional supplement (Nepro) and failed to prevent weight loss to Patient #10 when the recommendation of the Dietian was not followed. The facility census was 26.
Findings Included:
1. Review of facility-provided pressure sore tracking documentation from 07-12/09 revealed five patients developed a total of 12 pressure sores after admission to the facility.
Review of facility policies entitled, " Skin Care, Assessment and Maintenance of, " revised 07/16/08, and " Wound Assessment, issued 06/10/08, revealed all bedfast patients shall be turned every two hours unless contraindicated by a physician ' s order. The goal of nutritional assessment and management is to ensure that the diet of the patient with a wound contains nutrients adequate to support healing.
Review of Patient #5's nursing assessment, dated 12/07/09, revealed the patient had no skin breakdown on the coccyx (tailbone). The patient was admitted with a diagnosis of a recent colon resection. The patient was on a renal diet and weighed 145 pounds on admission.
Review of a Registered Dietitian ' s (RD) assessment dated 12/08/09, revealed the patient was an increased risk for nutritional deficits because of his/her age, and recent surgery. The patient also suffered from moderate malnutrition. The patient ' s albumin level (a protein in the blood-can be indicative of poor wound healing ability) was low at 3.0. The RD recommended a nutritional supplement called Nepro to be given twice daily.
Review of the Physician ' s orders dated 12/11/09 revealed an order for Nepro BID.
Review of all documentation regarding the provision of the Nepro revealed staff failed to document the percentage of the supplement consumed by the patient.
Review of patient weights revealed the patient had lost 14%, or 19 pounds, of his/her body weight from admission through 01/04/10.
During an interview on 01/05/10 at 3:03 p.m. the Chief Nursing Officer said the facility had no policy to document the percentage of a supplement; however, according to their corporate nurse it should be documented.
Review of the patient ' s Braden score (a tool used to assess risk for the development of pressure sores) on admission was " 20, " or considered no risk. The score remained " 20 " through the 12/28/09 assessment.
Observation on 01/05/10 at 10:53 a.m. revealed the patient had a Stage II pressure sore on the coccyx measuring 1.4 centimeters (cm) by 0.4 cm by 0.2 cm deep. The patient was very thin.
Review of pressure sore documentation revealed the patient developed a Stage II pressure sore on the coccyx on 12/28/09 that measured 1.0 cm by 0.5 cm by 0.2 cm.
Review of the patient ' s nursing assessments from admission through 01/04/10 revealed staff failed to consistently document the turning of the patient every two hours.





27727

2. Record review of the medical chart revealed Patient #9 was admitted to the facility on 8/27/09 for pulmonary support and ventilator weaning.

Record review of the Braden Scale (a tool for predicting pressure sore risk) dated 8/28/09 revealed the patient with a score of eleven which indicated High Risk (Total Score > 14.)

Record review of the Nursing Wound Documentation dated 8/28/09 revealed the patient was assessed as having a Stage (unable to read if the number was a 2 or a 3) pressure sore on the buttocks (wound # 1) with no identification as to where the pressure sore was located. The documentation also revealed the pressure sore was to be treated with Zinc Oxide BID (two times a day) (a medication which is used to treat or prevent minor skin irritations).

Record review of the Nursing Wound Documentation dated 8/28/09 revealed the patient was assessed as having a (wound # 3) on the buttocks with no identification as to where the pressure sore was located. The documentation also revealed the pressure sore was to be treated with Zinc Oxide (medication which is used to treat or prevent minor skin irritations) BID (two times a day) and PRN (as needed) after soilage.

Record review of the 24 Hour Patient Record & Plan of Care under the heading of Hourly Rounding revealed the staff had not documented "R" for Reposition for the following dates and times:
8/27/09 6:00 p.m. to 6:00 a.m.
8/28/09 6:00 p.m.
8/29/09 6:00 p.m., 7:00 p.m., 3:00 a.m.
8/30/09 5:00 a.m., 6:00 a.m.
9/1/09 1:00 a.m. through 6:00 a.m.
9/9/09 2:00 p.m. through 7:00 p.m.
9/12/09 3:00 a.m. through 5:00 a.m.
9/13/09 6:00 p.m. and 7:00 p.m.
9/15/09 11:00 a.m., 12:00 p.m., 2:00 p.m., 3:00 p.m.
9/17/09 1:00 a.m. through 6:00 a.m.
9/20/09 1:00 a.m. through 3:00 a.m.
9/26/09 3:00 p.m. through 7:00 p.m.
9/27/09 7:00 a.m. through 7:00 p.m.
9/29/09 12:00 p.m., 1:00 p.m., 5:00 p.m., 6:00 p.m., 7:00 p.m.
10/4/09 7:00 a.m. through 6:00 p.m.
10/7/09 9:00 p.m. through 11:00 p.m.
10/8/09 3:00 p.m. through 6:00 p.m.
10/9/09 7:00 a.m. through 4:00 p.m.

Record review of the 24 Hour Patient Record & Plan of Care under the heading of Weight revealed the following:
Admission weight 103 kg ( a unit of weight equal to 2.2 pounds)
Weight on 10/7/09 was 69.2 kg
No weight was recorded on the day of discharge.

Record review of the Nutrition Assessment dated 8/28/09 revealed the following information:
The assessment indicates severe malnutrition as evidenced by Albumin (Alb)/>BMI. (Albumin is a plasma protein which is needed to maintain blood volume). Body Mass Index (BMI) measures the relationship between weight and height.

Record review of the Dietitian Progress Notes dated 9/25/09 revealed the dietitian had recommended a calorie count and Glucerna (a supplement for diabetics) 1.2 with meals.

Record review of the dietitian Progress Notes dated 9/28/09 revealed the dietitian recommended an appetite stimulant (a drug which increases the appetite) and a bolus ( given in a single large dose) 1 x can of Jevity 1.2 (high protein medical nutritional supplement with fiber) after meal if by mouth intake was below 50 %.

Record review of the dietitian Progress Notes dated 10/06/09 revealed the dietitian recommended a Glucerna Shake and an appetite stimulant.

Review of the Physician Orders did not reveal any orders related to the dietitians recommendations.

During an interview on 1/6/10 at 9:15 a.m. Dietian L stated that documentation of dietary needs for a patient are written in the Progress Notes where the physician may read them and sometimes she will speak to the physician about dietary needs for a patient but does not document that he/she does so. He/she stated there was no policy or procedure to notify the physician of dietary needs.

3. Record review of Patient #10's medical record revealed the patient was admitted to the hospital on 5/18/09 for treatment of wounds of the right and left foot and right and left buttock.

Record review of Patient's Admission Database dated 5/18/09 Chief Complaint/Reason for Hospitalization (State in patient's own words) revealed the following information:
-Wound (unable to read the next word) to "B" (bilateral) lower extremities and buttocks (quartersize) Wound to mid back.
- Documentation revealed the patient was impaired in the following:
Bed Mobility, Transfers, Gait, Balance
-Activities of Daily Living (ADL's) Bathing and Dressing

Record review of Patient #10's Photographic Wound Documentation dated 5/19/09 revealed the following information:
-#1 Right top foot Type of Wound: Arterial with 1.6 x 1.7 cm with no tunneling, undermining and depth unknown
Exudate: odor none, Small amount of serosanguineous drainage slough, surrounding skin color pink and wound edges/surrounding tissue is normal for skin and peripheral tissue edema
-#2 Right 2nd toe Type of Wound Arterial with .5 x .7 with no tunneling, undermining, depth unknown, no odor, amount of serosanguineous drainage, pink/beefy red tissue and slough, surrounding skin color dark red purple, wound edges/surrounding tissue with peripheral tissue edema.
-#3 Right 3rd toe Type of Wound Arterial .6 x .8 cm with no tunneling or undermining, depth unknown, exudate not noted, wound bed pink/beefy red tissue and slough, surrounding skin color not documented, wound edges/surrounding tissue with peripheral tissue edema.
-#4 Right Right 4th toe Type of Wound Arterial with 2.8 x 3.0 cm with no tunneling, undermining depth .1 cm, no exudate documented, wound bed pink/beefy red tissue, slough surrounding skin color dark red purple, wound edges/surrounding tissue, normal for skin and peripheral tissue edema.
- #8 photograph revealed a picture of the patient's back with a wound measuring guide with a circled number 8. The surveyor was unable to clearly see the wound and no measurements were provided.

Record review of the Wound Progress Note dated 6/17/09 in part revealed the following information:
Wound locations:
#6 Left outer foot eschar present 3.5 x 2.0 cm
#7 Left heel eschar present 3.3 x 2.5 cm
#8 Right buttock Slough, bright red edges small amount of granulation 3.0 x 3/5 cm with f10 cc lock = 3.5 cm tunneling and a depth of 2.5 cm
#9 Left (unable to read) toe No open area red deep tissue injury 1.7 x 1.0 cm
#10 Left 4th toe open wound DTI (deep tissue injury) 1.2 x 1.2 cm
#11 Left 2nd toe eschar present .8 x 1.0 cm
#12 Left great toe with eschar present 3.5 x 3.0 cm
#13 Right below the knee amputation (BKA) .1 x 19.0 cm with staples and sutures dry and intact

Record review of the Physician's Orders dated 5/19/09 in part revealed the following information:
-Patient to be turned q (every) 2 hours side to side only.
Record review of the Physician's Orders dated 6/9/09 revealed in part the following information:
-Patient to be turned q 2 hrs Left side and back only. to be off of Rightr buttock at all times

-Record review of the 24 Hour Patient Record & Plan of Care - Hourly Rounding revealed no documentation of the patient being repositioned on the following dates and times:
On 5/19/09 from 6:00 p.m. through 6:00 a.m.
On 5/22/09 from 7:00 p.m. through 6:00 a.m.
On 5/23/09 from 7:00 a.m. through 6:00 p.m.
On 5/26/09 from 7:00 a.m. through 5:00 p.m.
On 5/27/09 from 7:00 a.m. through 7:00 p.m.
On 5/29/09 from 7:00 a.m. through 7:00 p.m.
On 6/3/09 from 10:00 a.m. through 6:00 p.m.
On 6/5/09 from 1:00 a.m. through 6:00 a.m.
On 6/10/09 from 7:00 p.m. through 6:00 a.m.
On 6/13/09 from 7:00 a.m. through 7:00 p.m.
On 6/14/09 from 7:00 a.m. through 7:00 p.m.
On 6/15/09 from 7:00 a.m. through 7:00 p.m.

During an interview on 1/12/10 Registered Nurse Q stated all patients are expected to be turned q 2 hours even if there is not a physician's order.

Based on observation and interview the facility failed to keep the wound cart in a secure area and locked when drugs were in the cart.

Observation on 1/5/10 at 11:10 a.m. revealed the unlocked and unattended wound cart in the hallway with an opened bottle of xylocaine 1% (a local anesthetic) with epinephrine (a local anesthetic)1:100,000 in one of the drawers.

During an interview on 1/5/10 at 11:25 a.m. Licensed Practical Nurse (LPN) K stated the cart should have been locked.

Based on observation and interview the facility failed to label a multi-use liquid container with the patient's name (Patient #2), intended use, and date initially opened. The facility census was 26.
Findings Included:
1. Observation on 01/04/10 at 4:02 p.m., revealed a 1000 milliliter (ml) bottle, ? full, of sterile water on Patient #2's bedside table. The bottle did not have any label indicating patient name, what it was to be used for, or when it was initially opened.
During an interview on 01/04/10 at 4:40 p.m., the Chief Nursing Officer said it was the facility's policy to date any multi-use container when opened.

Based on observation, interview and record review the facility failed to provide nutritional supplements to two of two patients reviewed with orders for supplements (Patients #5 and #6). The facility census was 26.
Findings Included:
1. Review of facility policies entitled, " Skin Care, Assessment and Maintenance of, " revised 07/16/08, and " Wound Assessment, issued 06/10/08, revealed the goal of nutritional assessment and management is to ensure that the diet of the patient with a wound contains nutrients adequate to support healing.
Review of Patient #5's nursing assessment, dated 12/07/09, revealed the patient was admitted on 12/17/09 with a diagnosis of a recent colon resection. The patient was on a renal diet and weighed 145 pounds on admission.
Review of a Registered Dietitian ' s (RD) assessment dated 12/08/09, revealed the patient was an increased risk for nutritional deficits because of his/her age, and recent surgery. The patient also suffered from moderate malnutrition. The patient ' s Albumin level (a protein in the blood) was low at 3.0. The RD recommended a nutritional supplement called Nepro to be given twice daily.
Review of the Physician ' s orders dated 12/11/09 revealed an order for Nepro BID.
Review of all documentation regarding the provision of the Nepro revealed staff failed to document the percentage of the supplement consumed by the patient.
Review of patient's weights revealed the patient had lost 14%, or 19 pounds, of his/her body weight from admission through 01/04/10.
During an interview on 01/05/10 at 3:03 p.m. the Chief Nursing Officer said the facility had no policy to document the percentage of a supplement; however, according to their corporate nurse it should be documented.
Observation on 01/05/10 at 10:53 a.m. revealed the patient had a Stage II pressure sore (partial thickness skin loss, usually appearing as a blister, or shallow crater) on the coccyx measuring 1.4 centimeters (cm) by 0.4 cm by 0.2 cm deep. The patient was very thin.
2. Review of Patient #6's History and Physical dated 12/17/09, revealed the patient was admitted with a diagnosis of chronic renal failure and diabetes.
Review of the RD assessment dated 12/18/09 revealed the patient's Albumin was 1.9 (low) and the RD recommended adding a protein supplement twice daily.
Review of the patient's Physician's orders dated 12/21/09 revealed the staff were add one scoop of ProMod (a protein supplement powder) to two of his/her feedings daily.
Review of the documentation regarding the ProMod from 12/21/09 through 01/05/10 revealed staff failed to consistently document the provision of the supplement.
Review of the patient's weights revealed the patient weighed 171 pounds on admission and on 01/04/10 weighed 165.4 pounds.

Based on observation, interview and record review the facility failed to follow infection control practices for three of six patients observed (Patients #2, #7, and #8), and for three additional random observations. The facility census was 26.
Findings Included:
1. Record review of Patient #7's medical chart revealed the patient was admitted to the facility on 12/29/09 for treatment of a complex abdominal wound and decubitus ulcer (pressure sore). The patient was in contact isolation.

Observation on 1/4/10 at 3:45 a.m. revealed Certified Nursing Assistance (C.N.A.) D, E and F enter the patients contact isolation room without washing their hands with soap and water or alcohol based hand sanitizer. The C.N.A.'s applied gloves and gowns but did not secure the gowns with ties at the neck or waist which allowed the gowns to slip down to mid torso. They proceeded to place the patient on a shower bed and C.N.A. D and E transported the patient out of the room still wearing the gloves and gowns. The patient's hands were not washed before leaving the room.

Observation on 1/6/10 at 12:25 p.m. revealed Radiology Tech P entered the patient contact isolation room without washing hands with soap and water or alcohol based hand sanitizer or gown and glove and proceeded to take an x ray. Radiology Tech P left the room and did not wash hands with soap and water or alcohol based hand sanitizer until the charge nurse reminded him he was in an contact isolation room at which time Radiology Tech P used the alcohol based hand sanitizer.

During an interview on 1/6/10 at 12:40 p.m. with Staff P, he/she stated he/she did not see the contact isolation sign. When asked how frequently he/she came to this facility, he/she stated "3-4 times a day."
2. Record review of Patient #8's medical chart revealed the patient was admitted to the facility on 9/23/09 with prolonged ventilator support. The patient was in contact isolation.

Observation on 1/5/10 at 8:55 a.m. revealed Registered Nurse (RN) H entered the patient contact isolation room with gown not tied at neck or waist which allowed the gown to slip down to her mid torso. RN H administered medications through the Gastrointestinal tube (a tube which enters the stomach). RN H then left the room and reentered the room without washing her hands with soap and water or alcohol based hand sanitizer and donned gloves and gown.

During an interview on 1/4/10 at 4:40 p.m. the Director of Clinical Services C stated she would expect the staff to gown and glove in the entry area of each room and to either use soap and water or foam when entering or leaving the room.

Record review of the facility's policy IC-III-4 Standard Precautions revealed in part the following information:
II. Policy
Gowns:
2. To put the gown on, close the gown securely so the back is completely covered and tie both waist and neck strings.
5. Gowns are also worn by personnel during the care of patient infected with epidemiologically important microorganisms to reduce the opportunity for transmission of pathogens from patients or items in their environment to other patients or environments.
6. When gowns are worn for these purposes, they are to be removed before leaving the patient's environment and hands are to be washed.

Record review of the facility's policy IC III-5 Enhanced Contact Precautions revealed in part the following information:
The policy of Select Specialty Hospital is to prevent transmission of highly transmissible or epidemiologically important infections by direct or indirect contact. Because of the fragility of the patient population and the high degree of MDRO ( multidrug resistant organisms) colonization (an organism which shows no symptoms) and infections at the time of admission, these have been expanded beyond the 2007 CDC (Center of Disease Control) Guidelines.

Principles
A. Sufficient precautions to control cross-infection in this category of isolation include proper hand hygiene, handling of linen, dressings and contaminated instruments, and the use of gowns, masks and gloves when stipulated.
B. This category includes excessive wound drainage, fecal incontinence, or other types of drainage or patient colonized or infected with MDRO's.
Procedures:
C. Specific Procedures:
3. Gowns should be worn when soiling will be likely to occur or when contact with the patient or environmental surfaces that have been contaminated will occur.
5. Hand hygiene with alcohol based cleanser must be performed upon entering and leaving the room. If hands are visible soiled or if contact isolation is in place for C-Diff (Clostridium difficile is a bacteria of the colon which causes symptoms from diarrhea to life-threatening inflammation of the colon) then hand washing with soap and water must be completed.
6. Non-sterile gloves are to be worn by persons having direct contact with the patient and the environment. Gloves must be removed before leaving the room.
14. ... The visitors should be instructed on the use of gowns, gloves and proper hand hygiene.
15. Transporting patients- Patient's hands must be cleansed before leaving the room.





12450

3. Review of Patient #2 ' s record revealed the patient was admitted on 11/25/09 with a diagnosis of a left below the knee amputation.
Review of the patient ' s laboratory results dated 12/31/09 revealed the patient was infected with Methicillin Resistant Staphylococcus Aureus (MRSA), and on contact isolation.
Observation on 01/04/10 from 3:40-4:15 p.m. revealed an unidentified staff member entered the patient ' s room with a gown and gloves in his/her hands and crossed the room the patient ' s roommate without washing his/her hands, and failed to put the gown and gloves on prior to entering the room.
4. Observation on 01/06/10 at 9:12 a.m. revealed a staff member in room #320, with a contact isolation sign on the doorway. This staff member ' s gown was not tied at the neckline.
5. Observation on 01/06/10 at 9:15 a.m. revealed a staff member in room #327, with a contact isolation sign on the doorway. This staff member ' s gown was not tied at the neckline or waistline.
6. Observation on 01/06/10 at 9:16 a.m. revealed a staff member in room #323, with a contact isolation sign on the doorway. This staff member ' s gown was not tied at the waistline and the ties were dragging on the floor in the doorway of the room. The staff member went back into the room to the bedside of the patient with the same gown on.

Based on observation, interview, and record reviews the facility failed to ensure the staff follow the facility's medication policy when the physician's orders were not followed in administering medications to one (Patient #3) of three patients.

Observation on 1/5/2010 at 9:45 a.m. revealed the Registered Nurse (RN) M administered the following medication by mouth instead of per tube as ordered by the physician:
-Methadone HCL(a medication used to treat pain) 5 mg
-Prednisone ( a drug used for inflammation)10 mg
-Simethicone (a drug used to reduce bloating, discomfort and pain caused by excess gas in the stomach or intestinal tract) 40 mg

-Record review of the Physician's Orders dated 12/26/09 revealed the following:
the route for Methadone was "per tube".
-Record review of the Physician's Orders dated 12/14/09 revealed the following:
The route for Prednisone was "per tube".
-Record review of the Physician's Orders dated revealed the following:
The route for Simethicone was "per tube".

-Record review of the facilities Policy titled Medication Administration revised 7/16/08 states in part the following:
Purpose:
To ensure the safe preparation and administration of medications.
Policy:
20. Follow the 6 Rights of medication administration. Administer.
5. By the Right route

-During an interview on 1/5/2010 at 10:00 RN M stated the patient's spouse had requested the medication be given by mouth instead of per tube.

During an interview on 1/6/10 at 10:03 a.m. the Director of Clinical Services C stated the nurse should have contacted the doctor to have the order changed if the patient's spouse wanted the medications given by mouth instead of per tube as ordered.