DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
452091 A. BUILDING __________
B. WING ______________
03/04/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
TYLER CONTINUECARE HOSPITAL (AT MOTHER FRANCES) 800 EAST DAWSON 4TH FLOOR, TYLER, TX, 75701
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A0115 Patient Rights
482.13
Corrected On:
19159 Based upon record review and interview, nursing failed to provide wound care for 1 of 9 patients reviewed in a time span from 1-6-2022 thru 1-24-2022 (18 days). There was no evidence that the wound care nurse provided wound care. The wound was a Stage 2 pressure wound on the coccyx on 1-6-22 (day after admission). There was no evidence of monitoring or assessment of the wound or wound care provided until 1-24-2022 when wound was assessed and was determined to be a large deep wound of the sacral area that was covered with eschar (a dry, dark scab). Actual harm occurred requiring surgical debridement of the wound due to lack of wound care, assessment, and monitoring of the wound. These deficient practices were determined to pose an Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.
A0144 Patient Rights: Care In Safe Setting
482.13(c)(2)
Corrected On:
19159 Based upon record review and interview, nursing failed to provide wound care for 1(#1) of 9 patients reviewed in a time span from 1-6-2022 thru 1-24-2022 (18 days). There was no evidence that the wound care nurse provided wound care. The wound was a Stage 2 pressure wound on the coccyx on 1-6-22 (day after admission). There was no evidence of monitoring or assessment of the wound or wound care provided until 1-24-2022 when wound was assessed and was determined to be a large deep wound of the sacral area that was covered with eschar (a dry, dark scab). Actual harm occurred requiring surgical debridement of the wound due to lack of wound care, assessment, and monitoring of the wound. Review of the medical record of Patient #1 revealed patient was a 74 year old male who had recently been hospitalized for multivessel coronary artery disease with severe Aortic Stenosis and Mitral Valve regurgitation. Patient had a 3 vessel cardiac bypass with aortic valve replacement and mitral valve replacement on 12/21/2021 and 2 chest tube placement. Postop he remained intubated and encephalopathic (changes in the brain that leads to an altered mental state). Other diagnoses included Acute Hypoxemic Respiratory Failure, Severe Sepsis, Hypernatremia, Gangrene of toes on both feet, and morbid obesity. Patient #1 was admitted on 1/5/2022. On 1/6/2022, patient was assessed by the wound care nurse, Staff # 5, for the first time. The patient was found to have an incision site of the chest from cardiac surgery on 12/21/2021. The wound was intact and open to air with no signs of infection. The patient also had an incision site to the left leg that was clean dry and intact with no signs or symptoms of infection. There was also a wound to the left medial thigh that was clean dry and intact with no signs of infection and no dressing. Patient was on a Bariatric bed which when used appropriately, is supposed to rotate the air within the mattress to relieve pressure areas. The patient had multiple bruising to bilateral upper and lower extremities. Staff #5 also documented the following: "Stage II to coccyx measures 1cm x 1.2 cm x0.2 cm. Small serosanguinous dranage. Buttocks and heels intact. Discoloration to toes on left and right feet. Recommend: 1. Turn q2hrs. Float heels to pillow or green boots 2. Venelex ointment to coccyx wound, may leave open to air or place sacral foam dressing. Change daily. 3. Calmoseptine barrier cream to buttocks and groin twice daily. Further review of the medical record on 2/22/2022 with the CNO (Staff #1) revealed day after day from 1/6/2022 with no documentation of wound care to the patient's coccyx pressure wound. Review of nursing flow sheets of review of wounds and skin care revealed no documentation of the patient having a pressure wound on his coccyx. While continuing reviewing the flowsheets, the CNO reported she had already reviewed the patient's medical record and found there was no documentation in the record of the patient's wound except for the initial wound assessment on 1/6/2022 until a note was found on 1/24/2022 in the nursing flowsheets. The wound care documentation on 1/24/2022 stated "Date and time first assessed 1/23/22@2200. Documented 1/24/2022 0538. Pre-existing: acquired this wound during this hospitalization. Location: Buttocks, Wound Location Orientation: Bilateral. Non-staged wound. Further record review revealed a wound care note written 1/25/22 by staff #5."Multiple bruising to bilateral upper and lower extremities. Partial thickness skin tear to left and right arms. Sternal incision resolving. Multiple scabs and bruising to periwound. Incision to left medial thigh well approximated, no drainage. Stage II to coccyx, bilateral buttocks, now is a deep tissue injury. Measures 10cm x 15 cm. Deep cherry and black color to wound bed. Small serosanquinous drainage with no odor. Deep tissue injury to left heel, 1cm x 1cm, light purple area, no drainage. Green boots in place. Stable Eschar to toes on left and right feet. Remains on bari-bed with low airloss mattress. Recommend: 1. Turn q 2 hours. Float heels to pillow or green boots. 2. Cleanse buttocks, coccyx wound daily with NS(normal saline), apply honey paste, cover with ABD pad . No tape. 3. Calmoseptine barrier cream to groin twice daily. 4. Cleanse skin tears to left arm with NS, apply xeroform gauze and telfa with kerlix. 5. Tegaderm dressing to right arm skin tears. Change every T,F, prn. An interview was continued with the CNO on 2/22/2022 at approximately 1230 in the conference room. The CNO reported she had talked to Staff #5 about why there was no documentation of assessment, pictures, or treatment notes for patient #1's wounds and there was little response from her other than I am sorry. The CNO reported the wound care nurse worked Mon-Wed-Fri and the bedside nurse is responsible for assessing the wound and providing treatment when the wound care nurse was not on duty. The CNO reported the facility had a wound care Nurse Practitioner full time prior to 12/21/21 that was provided by a contracted Wound Care Group. Since she had left, the Wound Care Group had provided Nurse Practitioners sporadically due to lack of available providers. The CNO stated the facility had a part time wound care nurse that was out on leave from 12/4/2021 - 1/24/22 and had recently returned. Review of Patient #1's medical record dated 1/27/2022 at 1452 (2:52pm) revealed a "Wound Care Provider Note" written by Staff #14. The note stated: "Assessment and Treatment Plan - 1. Bilateral buttocks unstageable pressure injuries - Continue Calmoseptine without dressing, offload with q 2 hr turning by nursing and alternating air mattress. Will discuss with PCP (primary care physician) and consent for debridement with responsible party. 2. Bilateral ischemic feet/toes - Continue painting BID with Betadine and monitor for stability of the necrotic tissue, should peel as the tissue underneath fills in, then we will see what remains viable tissue. 3. Bilateral upper extremity skin tears - continue non-adhesive like adaptic/Xerofoam and Kerlix wraps." This was the only documentation found that indicated the patient was seen by a contracted wound care provider. An interview was conducted with Staff #4 on 2/22/2022 in the afternoon. Staff #4 stated she was on leave when the patient was admitted and she had returned to work on 1/24/2022 but was not doing wound care when she returned. Staff #4 reported she had not cared for patient #1. Staff #4 reported she was on duty as a bedside nurse but one of her co-workers ask her if she would go look at her patient which was patient #1. Staff #4 stated she was not assigned to do wound care and she initially was not going to do it but her co-worker kept insisting. She looked at the wound and told the patient's nurse to be sure the foam dressing remained in place and to keep the area clean and dry. She also told her to try to turn the patient or at least prop with pillows to relieve pressure to that area. Staff #4 reported she talked with the family and instructed them on the use of the low air loss mattress and to check it to make sure it was on at all times. Staff #4 stated she was scheduled on 1/31/2022 and took measurements and pictures and consulted with the physician about surgical debridement. Review of physician notes (Staff # 15) dated 1/25/2022 @ 1408 (2:08pm) revealed "Assessment and Plan.... Sacral Ulcer - Notified today about large sacral ulcer with eschar formation. Wound care seen (sic) the patient. Will likely need debridement." This was the first documentation found by a physician regarding the sacral wound since the patients admission on 1/5/2022. Further review of physician's note revealed a Consult Note of Staff #17 (Trauma Surgeon) dated 1/31/2022. "74 year old male initially admitted to the hospital over a month ago with cardiac issues. Underwent CABG (Coronary Artery Bypass Graft), MVR (Mitral Valve Replacement), AVR (Aortic Valve Replacement). Persistent respiratory failure following that for quite some time. Currently with tracheostomy. Pending PEG (Percutaneous Endoscopic Gastrostomy - surgically placed feeding tube). Anticoagulated with his recent valve replacements; currently on therapeutic Lovenox. Patient has a very large at least stage III sacral decubitus ulcer with necrotic skin and eschar. Consulted for surgical debridement. Imaging reviewed of the wounds with the patient's wife at the bedside as she had not seen them before. We discussed surgical debridement procedure with the patient's wife as well as the required postoperative wound care. With the location I suspect he has a high likelihood of needing a diverting colostomy as well for wound healing particularly with his significant deconditioning and neurological issues." Review of "Immediate Postoperative Note" dated 2/2/2022 revealed the following: Pre-Procedure Diagnosis: Sacral Decubitus Ulcer Post-Procedure Diagnosis: Sacral Decubitus Ulcer, Stage 4 Procedures Performed: 1. Excisional debridement of sacral decubitus ulcer (skin, fat, fascia and muscle 12x8x4cm) 2. Wound Vac placement (12x8x4 cm).... Findings: Necrotic and ischemic tissue including some mucle (sic) bilaterally. Extended onto the sacrum without appreciable osteomyelitis. Wound vac placed. No signs of infection or purulence......
A0385 Nursing Services
482.23
Corrected On:
19159 Based upon record review and interview, the facility failed to ensure nursing was conducting wound assessments during their daily and/or shift assessments for 1 (#1) of 9 patients reviewed. Nursing flowsheets where nurses documented their assessments had no mention of a pressure wound to the coccyx of patient #1. From 1/6/2022 through 1/23/2022 (16 days), there was no documentation that Patient #1's pressure wound on his coccyx was assessed or that the wound even existed. Refer to TAG A-0395
A0395 Rn Supervision Of Nursing Care
482.23(b)(3)
Corrected On:
19159 Based upon record review and interview, the facility failed to ensure nursing was conducting wound assessments during their daily and/or shift assessments for 1 (#1) of 9 patients reviewed. Nursing flowsheets where nurses documented their assessments had no mention of a pressure wound to the coccyx of patient #1. From 1/6/2022 through 1/23/2022 (16 days), there was no documentation that Patient #1's pressure wound on his coccyx was assessed or that the wound even existed. Review of the medical record of Patient #1 revealed patient was a 74 year old male who had recently been hospitalized for multivessel coronary artery disease with severe Aortic Stenosis and Mitral Valve regurgitation. Patient had a 3 vessel cardiac bypass with aortic valve replacement and mitral valve replacement on 12/21/2021 and 2 chest tube placement. Postop he remained intubated and encephalopathic (changes in the brain that leads to an altered mental state). Other diagnoses included Acute Hypoxemic Respiratory Failure, Severe Sepsis, Hypernatremia, Gangrene of toes on both feet, and morbid obesity. Review of nursing notes and nursing flow sheets revealed from the time the patient was admitted on 1/5/2022 until 1/23/2022 (17 days) there was no documentation regarding the patient having a pressure wound or treatment of a pressure wound. The initial RN assessment on the day of admission (1/5/2022) failed to identify there was a pressure wound to patient #1's coccyx. RN Daily and/or shift assessments did not mention the pressure wounds to the coccyx or buttocks. There was no documentation of PCAs (Patient Care Associates) reporting skin issues with patient #1. On 1/6/2022, patient was assessed by the wound care nurse, Staff # 5, for the first time. The patient was found to have an incision site of the chest from cardiac surgery on 12/21/2021. The wound was intact and open to air with no signs of infection. The patient also had an incision site to the left leg that was clean dry and intact with no signs or symptoms of infection. There was also a wound to the left medial thigh that was clean dry and intact with no signs of infection and no dressing. Patient was on a Bariatric bed which, when used appropriately, is supposed to rotate the air within the mattress to relieve pressure areas. The patient had multiple bruising to bilateral upper and lower extremities. Staff #5 also documented the following: "Stage II to coccyx measures 1cm x 1.2 cm x0.2 cm. Small serosanguinous dranage. Buttocks and heels intact. Discoloration to toes on left and right feet. Recommend: 1. Turn q2hrs. Float heels to pillow or green boots 2. Venelex ointment to coccyx wound, may leave open to air or place sacral foam dressing. Change daily. 3. Calmoseptine barrier cream to buttocks and groin twice daily. Further review of the medical record on 2/22/2022 with the CNO (Staff #1) revealed day after day from 1/6/2022 with no documentation of wound care to the patient's coccyx pressure wound. Review of nursing flow sheets of review of wounds and skin care revealed no documentation of the patient having a pressure wound on his coccyx. While continuing reviewing the flowsheets, the CNO reported she had already reviewed the patient's medical record and found there was no documentation in the record of the patient's wound except for the initial wound assessment on 1/6/2022 until a note was found on 1/24/2022 in the nursing flowsheets. The wound care documentation on 1/24/2022 stated "Date and time first assessed 1/23/22@2200. Documented 1/24/2022 0538. Pre-existing: acquired this wound during this hospitalization. Location: Buttocks, Wound Location Orientation: Bilateral. Non-staged wound." Further record review revealed a wound care note written 1/25/22 by staff #5."Multiple bruising to bilateral upper and lower extremities. Partial thickness skin tear to left and right arms. Sternal incision resolving. Multiple scabs and bruising to periwound. Incision to left medial thigh well approximated, no drainage. Stage II to coccyx, bilateral buttocks, now is a deep tissue injury. Measures 10cm x 15 cm. Deep cherry and black color to wound bed. Small serosanquinous drainage with no odor. Deep tissue injury to left heel, 1cm x 1cm, light purple area, no drainage. Green boots in place. Stable Eschar to toes on left and right feet. Remains on bari-bed with low airloss mattress. Recommend: 1. Turn q 2 hours. Float heels to pillow or green boots. 2. Cleanse buttocks, coccyx wound daily with NS(normal saline), apply honey paste, cover with ABD pad . No tape. 3. Calmoseptine barrier cream to groin twice daily. 4. Cleanse skin tears to left arm with NS, apply xeroform gauze and telfa with kerlix. 5. Tegaderm dressing to right arm skin tears. Change every T,F, prn. Review of the electronic medical record revealed the nursing assessment was entered into a flowsheet with a pre-populated review of systems and care needs that can be documented with an initial and date/time. Some of the areas may not apply to the patient if they are not experiencing any problems in those areas. Patient #1's pressure wound was not pre-populated on the flowsheet so it was never assessed and documented from 1/6/22 thru 1/23/22. Review of nursing policy and procedures revealed no policy that outlined how to conduct Daily or Shift Nursing Assessments or Head to Toe Assessments. A total of 11 nurses were responsible for the care of patient #1 over a period of 37 nursing shifts (16 days). At some point during those 16 days or 37 shifts, someone had to provide personal care, bathe the patient, or reposition patient and know that the pressure wound that measured 10x15 cm. existed.
A0749 Infection Control Program
482.42(a)(1)
Corrected On:
43853 Based on observation and interview the hospital failed to ensure methods were in place to prevent and/or control the transmission of infections by ensuring that: A. three of three Nutrition Rooms (H42049, H42034, B42002) and one of one rooms labeled "Clean Utility" that also contained patient nourishment supplies were maintained in a clean and sanitary manner and three of three Refrigerator/Freezer inspection logs completed; B. clean supplies were maintained in a manner to prevent contamination in two of two Clean Utility/Storage rooms (B42014 and B42001) C. water leaks were repaired and damaged ceiling tiles replaced; D. two of three medication dispensing machines were clean and free of debris, and that the floors were maintained in 1 of 2 nurses stations observed. Findings included: During an initial tour of the facility conducted with the CEO on 02/22/22 at 10:15 am the following was observed: A. Three of three patient Nutrition rooms were found to have unsanitary conditions (H42049, H42024, B42002). 1. Nutrition Room H42049 was observed on 02/22/22 at 10:16 am with the CEO. The lower shelf of the patient nutrition refrigerator was dirty with debris and spots of a spilled substance. The interior walls of the microwave were observed to be caked with splattered food debris. The glass rotating dish was dirty and had food debris and dried liquid substances on it, the ceiling of the microwave was covered in a thick coating of splattered food debris, the interior of the microwave door had splatters of food. The "Patient Nourishment Refrigerator Log" was reviewed at 10:21 and it was found that the log was incomplete for the month of February 2022 (02/01-02/22/22). a. For one of 22 days (02/21/22) there was no documentation of the temperatures having been verified to be within range documented on the log's sections for "Freezer Temperature" and "Refrigerator Temperature". b. The section of the log titled "Refrigerator/Freezer" had not been completed for 11 of 22 days (02/03-02/06, 02/11-02/13 and 02/17-02/20). There was no evidence staff had inspected the refrigerator or freezer on these dates to determine if patient food/drink items were within date if food items brought in for specific patient's/family were labeled with the patient/family name, date, room number. There was also no documentation on the log in the section titled "Clean & Discard" for these same dates indicating whether staff had cleaned the refrigerator/freezer or inspected to discard any expired items. c. The log also had a section to document the required monthly thermometer battery change that had not been completed, it could not be determined if the batteries had been changed at the first of the month. 2. Nutrition Room H42034 was observed on 02/22/22 at 10:34 am with the CEO. The interior of the microwave was observed to be caked with splattered food debris. The glass rotating dish was dirty and had food debris and dried liquid substances on it, the ceiling of the microwave was covered in a thick coating of splattered food debris, the interior of the microwave door had splatters of food. A styrofoam meal container was found on the bottom shelf labeled for a patient and dated 02/10/22. The external thermometer on the freezer reflected a temperature of 1F. The thermometer display for the acceptable temperature range reflected 50F-86F. Per the instructions on the "Patient Nourishment Refrigerator Log" the freezer temperature should be "at 10degrees F or less". The thermometer on the refrigerator indicated an acceptable temperature range of 26F-57F with a current temperature of 40F. The thermometer alarms were in the "off" position. The interior walls of the microwave were observed to be caked with splattered food debris. The glass rotating dish was dirty with food debris and dried liquid substances on it, the ceiling of the microwave was covered in a thick coating of splattered food debris, the interior of the microwave door had splatters of food. 3. Clean Utility Room B42014 was observed on 02/22/22 at 10:51 am with the CEO. This room contained patient nutrition supplies. A red cannister containing "Harney & Sons Holiday Tea" was observed in a cabinet along with other patient nutrition items. The cannister of tea bags was date stamped as "Best by 19 Sep 2020". The front outer edge of the upper cabinet shelf had drips of a dried reddish brown substance. The top drawer was found to contain two loose condiment packets of Ketchup, seven salt packets, a red measuring scoop, a loose screw approximately 1' long. The drawer was dirty with debris and the appearance of a dried liquid substance. The 2nd drawer was found to contain packages containing commercial size coffee packets. The drawer had loose coffee grounds and what appeared to be a dried liquid substance. The bottom drawer contained individually sealed packages of disposable plastic spoons. The drawer had loose salt packets and dirt, debris and what appeared to be a dried liquid substance under the packets of spoons. The "Patient Nourishment Refrigerator Log" was reviewed at 10:53 am and it was found that the log was incomplete for the month of February 2022 (02/01-02/22/22). a. For one of 22 days (02/21/22) there was no documentation of the temperatures having been verified to be within range documented on the log's sections for "Freezer Temperature" and "Refrigerator Temperature". b. The section of the log titled "Refrigerator/Freezer" had not been completed for 11 of 22 days (02/03-02/06, 02/10-02/13 and 02/18-02/20). There was no evidence staff had inspected the refrigerator or freezer on these dates to determine if patient food/drink items were within date if food items brought in for specific patient's/family were labeled with the patient/family name, date, room number. There was also no documentation on the log in the section titled "Clean & Discard" for these same dates indicating whether staff had cleaned the refrigerator/freezer or inspected to discard any expired items. c. The log also had a section to document the required monthly thermometer battery change that had not been completed, it could not be determined if the batteries had been changed at the first of the month. 4. Nutrition Room B42002 was observed on 02/22/22 at 11:07 am with the CEO. The lower shelf and bottom drawers of the patient nutrition refrigerator were dirty with debris and spots of a spilled substance. The interior walls of the microwave were observed to be caked with splattered food debris. The glass rotating dish was dirty and had food debris and dried liquid substances on it, the ceiling of the microwave was covered in a thick coating of splattered food debris, the interior of the microwave door had splatters of food. In the bottom drawer of the cabinet two large bags of chips were found opened and almost empty, a bag containing a "Sunbeam" partial loaf of bread and stamped "Best if used by 02/09/22", and an 8oz. open container of "Chick Fil A" condiment sauce that was approximately ¼ full. The condiment was labeled "Refrigerate after opening". There was also a black plastic plate, a ziptop bag containing loose unlabeled crackers and an empty disposable plastic storage bowl with a red lid. The CEO was asked if these items were for patients or if staff kept personal items in the nourishment room. She responded that the items appeared to belong to staff but that they weren't supposed to store them in this area. The "Patient Nourishment Refrigerator Log" was reviewed at 11:11 am and it was found that the log was incomplete for the month of February 2022 (02/01-02/22/22). a. The section of the log titled "Refrigerator/Freezer" had not been completed for 13 of 22 days (02/03-02/06, 02/10-02/13 and 02/16-02/20). There was no evidence staff had inspected the refrigerator or freezer on these dates to determine if patient food/drink items were within date if food items brought in for specific patient's/family were labeled with the patient/family name, date, room number. There was also no documentation on the log in the section titled "Clean & Discard" for these same dates indicating whether staff had cleaned the refrigerator/freezer or inspected to discard any expired items. c. The log also had a section to document the required monthly thermometer battery change that had not been completed, it could not be determined if the batteries had been changed at the first of the month. The instructions on the "Patient Nourishment Refrigerator Log" were as follows: "Procedure: Daily- Check refrigerator & freezer for 1) correct temp 2) expiration dates 3) spills 4) patient name, room # and date on all food/drink brought from outside hospital. Immediately- Notify Charge Nurse #1632 of improper temperatures or malfunctions. Out of date items will be removed & discarded (Food prepared outside of hospital is discarded 2 days after time received) Monthly- Thermometer batteries must be changed 1st of each month & when low Name of person changing battery:___________________________" B. Storage room B42001 was observed on 02/22/22 at 11:02 am with the CEO. This room was used to store medical supplies such as IV solution bags, packages of sterile tubing, etc. The items were being stored in blue plastic bins. The bins were found to be dirty with debris and some having what appeared to be dried liquid substances spilled into them. C. During the intial tour at 10:42 am with the CEO observations were made of stained ceiling tiles located along the main hallway, outside the Case Manager's office (H42033). There were two ceiling tiles with brown water stains, one stain was approximately 6" across and the adjoining tile also had a brown water stain approximately 2-3" in size. The CEO was asked if this was an active leak or old and she indicated that it was an active leak. She commented that the building was quite old and they had made several repairs to the roof and had "redone" it but that it still leaked in this area. During a tour of another main hallway directly outside of patient rooms B405 at 11:16 am observed another ceiling tile with two brown water stains each measuring approximately 2-3" in size and directly across the hall and just outside patient room B408 observed and additional ceiling tile with a dark brown water stain measuring approximately 4-6" in size. D. A tour of a nurses station at 10:44 am observed that the lower shelf/bins of the medication dispense machine appeared dirty grime and with debris. Additionally there was a build up of floor wax in front of the medication dispense machine and the adjoining document shred bin. Tour of 2nd nurses station at 10:49 observed a medication dispense machine with lower shelf having the appearance of being dirty with black smudges.