HospitalInspections.org

Based on medical record review, facility document review, and staff interviews it was determined that nursing staff failed to supervise and evaluate the nursing care for 1 out of 6 patients in the sample (Patient #5). Findings include:

I. Weights
Facility policy titled "Standards of Care and Professional Nursing Practice" states, "...The RN (registered nurse) plans...for the provision of quality patient care as evidenced by: The provision and coordination of nursing care... The RN and/or other members of the health care team implement interventions that are identified in the plan of care..."

Medical record review of Patient #5 revealed:
The patient was admitted on 4/25/23 with a diagnosis of failure to thrive - related to Niemann-Pick disease.

Orders placed to record the patient's weight once on the following dates:
5/3/23
5/8/23
5/9/23
Order placed to record weight every 7 days was placed on 5/11/23.

The following weights were recorded:
53.5 kg on 4/25/23 at 4:47pm
54.1 kg on 4/28/23 at 3:31pm
50.0 kg on 5/7/23 at 3:17pm
54.1 kg on 5/11/23 at 11:33am

Weights were not recorded as ordered on 5/8/23 and 5/9/23.

These findings were confirmed by Employee #7 on 7/24/23 at 11:04am.


II. Turns
Medical record review of Patient #5 revealed:
In an interview on 7/25/23 at 9:39am, Employee # 18 reviewed and demonstrated that as nurses are inputting skin assessment findings into the EMR, pop-ups are triggered when assessment findings indicate the patient has an increased risk for skin integrity. These pop-ups supply the nurses with potential interventions that they can then select from that can be implemented to prevent negative outcomes for skin integrity. When reviewing the record for Patient #5 turning or repositioning the patient every 2 hours was selected as a nursing intervention to be implemented.

On 4/26/23 a validated pressure injury was documented located on the patient's sacrum/coccyx at 8:09am. Documentation included a picture of the skin abnormality.

Patient was repositioned on the following dates and times:
4/26/23 at 2:00 am
4/26/23 at 6:30 am (4 hours and 30 minutes)
4/26/23 at 9:42 am (3 hours and 12 minutes)
4/26/23 at 2:20pm (4 hours and 38 minutes)
4/26/23 at 8:19pm (5 hours and 59 minutes)

4/27/23 at 12:40am
4/27/23 at 3:00pm (14 hours and 20 minutes)

4/28/23 at 4:16am
4/28/23 at 11:00am (6 hours and 44 minutes)
4/28/23 at 3:03pm (4 hours and 3 minutes)
4/28/23 at 7:49pm (4 hours and 46 minutes)

In an interview with on 7/24/23 at 1:41pm Employee #7 stated the expectation would have been for the patient to have been turned every 2 hours during these times and confirmed the above findings.

A nursing assessment dated 4/30/23 at 8:45am noted that the pressure injury status was deteriorating based on the last image.

On 5/1/23 at 1:51pm a Validated Pressure Injury Document verified that the wound had progressed to a Stage 2 Pressure Injury.

Based on observation, policy review, and staff interview, it was determined that for 1 of 2 patients (Patient #3) observed, it was determined that hospital staff failed to prepare, administer, secure and/or label medication according to facility's policies and procedures. Findings include:

Facility policy titled "Medication Administration" stated, "...Medications may NOT be stored at the patient's bedside and will be secured at all times..."

Facility policy titled "Enteral tube feeding, gastric" stated, "...Make sure that the enteral formula container is labeled with the patient's identifiers...date and time that the formula was hung...initials of the person who prepared, hung, and checked the enteral formula against the order, expiration date and time...Label the enteral administration set with the date and time that it was first hung..."

A. During an observation of Patient #3 on 7/24/2023 from 9:25 AM to 9:40 AM the following was observed.

1. The following medications were found unattended on the patient ' s bedside table:

-a bottle of Dextromethorphan quinidine 20mg/10mg Nuedexta.

-Multivitamin 1 tab in an unopened blister pack.

-Vitamin D3 1000 units 1 tab in an unopened blister pack.

-Olanzapine 5mg tab X 2 in unopened blister packs.

-Thiamine 100mg tab in an unopened blister pack.

-Folic acid 1mg in an unopened blister pack.

2. A 1000ml container of Osmolyte was infusing at 110cc an hour via an enteral feeding pump into Patient #3's Peg tube that was observed coming out of the top of his abdominal binder. A 1000ml bag of clear fluid was hanging on an IV pole piggybacked into the Peg tube. No label containing Patient #3's name, room number, date, time, initials of person who hung the feeding or the flush bag, expiration date and time was noted on the container of Osmolyte or the flush bag. Enteral administration set tubing along with flush bag tubing with no date or time noted.

These findings were confirmed on 7/24/2023 at 9:37 AM by Employee #6.

Based on medical record review, facility document review, and staff interviews it was determined that the facility failed to provide appropriate numbers of qualified personnel to furnish the rehabilitation services offered by the hospital in accordance with acceptable standards of practice. Findings include:

Facility policy "Provision of Patient Care Plan" stated, "... ChristianaCare leaders are responsible for providing oversight of patient care services that are appropriate for the scope and level of care required by the populations served ...Leaders provide for a sufficient number and mix of individuals to support safe, quality care, treatment and services ..."

Occupational Therapy
Staffing documentation for the department of Occupational Therapy [OT] for the week of 6/12/23 - 6/16/23 revealed:
-The expected number of shifts covered by staff was 64; the actual coverage was 36.5 (a difference of 27.5 shifts)
-There were an estimated 147 missed visits for the week

During an interview on 7/26/23 at 10:12 am Employee # 15 indicated that difficulty with staffing was a cause for missed visits.

Physical Therapy
Staffing documentation for the department of Physical Therapy [PT] for the week of 5/3/23 - 5/9/23 revealed:
-There were an estimated 739 missed visits for the week.

During an interview on 7/25/23 at 10:41am Employee # 19 noted that there is not enough staff to meet recommended treatment frequencies.

During an interview on 7/26/23 at 9:28 am Employee # 13 indicated that difficulty with staffing was a cause for missed visits.

During an interview on 7/26/23 at 9:28am with Employee # 14 indicated there has been an increased volume in service needs post COVID. PT has been having high demands on per diem staff, which can increase the likelihood of missed visits.

Based on medical record review, facility document review, and staff interviews it was determined that the facility failed to provide rehabilitation services in accordance with acceptable standards of practice for 2 out of 6 patients sampled (Patient # 1 and 5). Findings include:

Facility policy titled "Provision of Patient Care Plan" stated, " ...The process of caring for a patient includes: planning care, providing care, monitoring and determining the outcomes/response of care, modifying care, and coordinating follow-up. 1. Medical, dental, nursing, pharmacy, nutrition support, rehabilitation, social work and other services may carry out these activities. 2. Care is planned and provided ... by qualified individuals ... "

Physical Therapy [PT]:
Medical record review of Patient #5 revealed:
A PT evaluation was completed on 4/26/23 and a plan of care was developed for the patient to receive PT treatments 4-6 times per week.

For the week of 4/26/23 - 5/2/23 the patient was seen on 4/26/23, 4/28/23, and 5/1/23. (missing 1 PT treatment, per the plan of care)

For the week of 5/3/23 - 5/9/23 the patient was seen on 5/5/23 and 5/8/23. (missing 2 PT treatments, per the plan of care)

During an interview on 7/25/23 at 10:41am Employee # 19 noted that there is not enough staff to meet recommended treatment frequencies and confirmed the findings above.

Medical record review for Patient #1 revealed:
A PT evaluation was completed on 5/15/23 and a plan of care was developed for the patient to receive PT treatments 2-3 times per week.

For the week of 6/6/23 - 6/12/23 there is no evidence of the patient receiving PT treatments (missing 2 treatments).

For the week of 6/13/23 - 6/19/23 the patient was seen on 6/13/23 (missing 1 PT treatment).

During an interview on 7/26/23 at 9:28 am Employee # 13 indicated that difficulty with staffing was a cause for missed visits and confirmed the findings above.

Occupational Therapy [OT]
Medical record review for Patient #1 revealed:
An OT evaluation was completed on 5/15/23 and a plan of care was developed for the patient to receive OT treatments 1-2 times per week.

For the week of 6/12/23 - 6/18/23 the patient did not receive OT services (missing 1 OT treatment).

During an interview on 7/26/23 at 10:12 am Employee # 15 indicated that difficulty with staffing was a cause for missed visits and confirmed the findings above.