HospitalInspections.org

A. Based on document review and interview, it was determined, for 1 of 5 clinical records reviewed (Pt. #1), the hospital failed to ensure wound assessment was completed each shift, as required by policy.

Findings include:

1. Hospital policy No. ADM 002, titled, "Assessment and Reassessment of Inpatients", revised 9/2013, was reviewed on 3/20/14 at 2:25 PM. The policy required, "A nursing reassessment is performed at least once each shift. Focused reassessments are also performed..."

2. On 3/17/14 between 10:40 AM and 4:00 PM, Pt. #1's clinical record was reviewed. Pt. #1 was a 68 year old male, admitted on 4/19/13, with diagnoses of multiple decubitus and pressure ulcers (penile, scrotal, and sacral), left leg above the knee amputation with dry gangrene, and left upper extremity deep vein thrombosis. Pt. #1's wound assessment documentation, required each 12 hour shift, lacked 2 of 53 shift wound assessments (5/8/13 - 7 PM to 7 AM and 5/11/14 - 7 AM to 7 PM). Pt. #1 was discharged, in stable condition, to a nursing home on 5/15/13.

3. On 3/19/13 at approximately 10:00 AM, an interview was conducted with a quality coordinator (E #7). E #7 reviewed Pt. #1's wound assessment documentation and stated Pt. #1's wound care assessments for 5/8/13, 7 PM to 7 AM and 5/11/14, 7 AM to 7 PM were missing.




19840


B. Based on document review and interview, it was determined, for 3 of 5 clinical records reviewed (Pts. #1, 3, & 4), the Hospital failed to ensure patients with pressure ulcers and/or patients identified at risk for skin breakdown, were turned every two hours, as required by policy.

Findings include:

1. The hospital policy No. PCS 372, titled, "Skin Care Prevention Protocol", reviewed by the hospital on 2/11, was reviewed by the surveyor on 3/19/14 at approximately 3:30 PM. The protocol required, "To provide basic prevention measures to prevent skin breakdown in all patients admitted... The Skin Risk Assessment (Braden Scale) is completed by the RN... A score of 18 or below indicates risk... If a patient is at risk... Reposition patient every two hours...."

2. On 3/17/14 between 10:40 AM and 4:00 PM, Pt. #1's clinical record was reviewed. Pt. #1 was a 68 year old male, admitted on 4/19/13, with diagnoses of multiple decubitus and pressure ulcers (penile, scrotal, and sacral), left leg above the knee amputation with dry gangrene, and left upper extremity deep vein thrombosis. Pt. #1's skin risk assessment (Braden score) dated 4/19/13 at 7:04 AM was 16. Subsequent Braden scores were 9 on 4/24/13, 11 on 5/1/13, and 14 on 5/15/13. Pt. #1 was at risk of further skin breakdown and should have been turned every 2 hours.

3. Documentation of turning Pt. #1 every 2 hours, during the first 8 days of hospitalization, was missing on 4 of 16 shifts (4/21/13 - 7 AM to 7 PM; 4/25/13 - 7 AM to 7 PM; 4/26/13 - 7 AM to 7 PM; and 4/26/13 - 7 PM to 7 AM).

4. The clinical record for Pt. #3 was reviewed on 3/19/14 at approximately 10:30 AM. Pt. #3 was a 59 year old male, admitted on 3/10/14, with a diagnosis of infection and inflammation due to indwelling catheter. The admission wound assessment dated 3/11/14, included a type II pressure ulcer in the medial coccyx area. Pt. #3's Braden score was 16. The record lacked documentation that Pt. #3 was turned or repositioned on 3/18/14 from 7:00 AM to 3:00 PM.

5. The clinical record for Pt. #4 was reviewed on 3/19/14 at approximately 1:30 PM. Pt. #4 was a 54 year old female, admitted on 2/26/14, with diagnoses of peripheral vascular disorder, aftercare orthopedic, and end stage renal disease. The admission wound assessment on 2/27/14 at 1:13 AM, included a reddened pressure ulcer on the right buttock, and a Braden score of 17. Pt. #4's record lacked documentation's for two hour turning for the day shift (7:00 AM - 7:00 PM) on 3/3/14 and 3/12/14 and for the night shift (7:00 PM - 7:00 AM) on 2/28/14, 3/2/14, 3/5/14, and 3/13/14.

6. On 3/19/13 at approximately 10:00 AM, an interview was conducted with a quality coordinator (E #7). E #7 reviewed Pt. #1's turning record and stated there was no documentation for turning for 4/21/13 - 7 AM to 7 PM; 4/25/13 - 7 AM to 7 PM; 4/26/13 - 7 AM to 7 PM; and 4/26/13 - 7 PM to 7 AM.

7. The findings for Pts. #3 & 4 were discussed with the director of organization performance improvement during an interview on 3/19/14, at approximately 2:00 PM. The director stated patient care technicians document the number of times patients are turned at the end of their shift and acknowledged that the documentation for turning was missing or incomplete for Pts. #3 & 4.
surveyors 19840 & 19843

C. Based on document review and interview, it was determined, for 2 of 5 clinical records reviewed (Pts. #1 & 5), the Hospital failed to ensure nutrition, including nutritional supplements, were provided as ordered.

Findings include:

1. Hospital policy No. PCS 470, titled, "Meditech Documentation Standards", revised 1/2010, was reviewed on 3/20/14 at 2:30 PM. The policy required, "7. The PCT [patient care technician] gives totaled intake and output information to the RN for inclusion into the RN's I&O assessment in Meditech... 8. The RN documents intake and output every 9 hours... (regardless if working 8 or 12 hour shift) including the following measurements: a. oral..."

2. On 3/17/14 between 10:40 AM and 4:00 PM, Pt. #1's clinical record was reviewed. Pt. #1 was a 68 year old male, admitted on 4/19/13, with diagnoses of multiple decubitus and pressure ulcers (penile, scrotal, and sacral), left leg above the knee amputation with dry gangrene, and left upper extremity deep vein thrombosis. Pt. #1 ' s nutrition assessment dated 4/20/13 at 11:04 AM, indicated Pt. #1 was at nutritional risk due to " altered skin integrity, mental/cognitive deficits, malnutrition, dysphagia, renal/hepatic insufficiency, underweight and altered visceral protein. " Pt. #1's nutritional assessment required a daily 1,411 - 1,628 kilocalorie (kcal) diet with 48 to 64 grams of protein and 1,411 to 1,628 ml of water.

3. Pt. #1 ' s physician ' s order dated 4/20/13 at 11:09 AM, included a pureed diet with liquid supplements " Vary oral supplements three times each day with meals " . Documentation of meals consumed during the first full 9 days (4/20/13 to 4/28/13) of Pt. #1 ' s hospitalization was missing for 7 of 9 lunch meals and 8 of 9 dinner meals.

4. Pt. #1's oral intake record during the first 9 days of hospitalization (4/21/13 through 4/29/13) did not separate nutritional supplements from other fluids i.e. water and was completed at the end of each shift, not after each meal. It could not be determined the amount of nutritional supplements Pt. #1 consumed.

5. On 3/19/14 at 3:10 PM, an interview was conducted with the director of organizational performance improvement (E #2) and the manager of 2N (E #5). E #5 reviewed documentation for Pt. #1 ' s nutritional supplements from 4/21/13 through 4/29/13. E #5 stated Meditech documentation does not reflect if 1, 2 or 3 cans of nutritional supplement were consumed each day. E #5 stated the oral intake record include all fluids consumed.

6. Between 4/21/13 and 4/29/13, Pt. #1's oral intake ranged from 370 ml to 1,250, which did not meet the clinical dietician ' s 1,411 - 1,628 ml per day "water" requirement. Pt. #1 did not have intravenous fluids or other nutritional/fluids access.

7. During an interview with a clinical dietician (E #6) on 3/19/14 at approximately 10:00 AM, E #6 stated dietary supplements consist of 250 to 300 calories and 8 to 15 grams of protein. The supplements are recorded on the oral intake record by nursing. However, oral intake includes all fluids consumed, not just supplements. Dietary staff discover if patients are not consuming the supplements when the dietary aid delivers food trays and notices unused cans of supplement stacking up.

8. Pt. #1 ' s discharge summary dated 5/15/13, included, " The patient was discharged in stable medical condition [to a nursing home] ... on 5/15/13. "

9. The clinical record for Pt. #5 was reviewed on 3/19/14 at approximately 2:15 PM. Pt. #5 was an 88 year old male admitted on 2/13/14, with a diagnosis of peritonitis. A diet order for oral supplemental feeding, dated 3/10/14 included, "Resource drink supplement, for breakfast and lunch." The record lacked documentation of any oral supplement given on 3/10/14 and 3/11/14. In addition the the record indicated Pt. #1 received or consumed the oral supplement once daily instead of breakfast and lunch on 3/12/14 through 3/17/14, and 3/19/14.

10. Pt. #5's lack of nutritional supplement documentation was discussed with the Director of Organization Performance Improvement during an interview on 3/19/14, at approximately 2:00 PM.
surveyors 19840 & 19843