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Based on medical record review and staff interview, the facility failed to ensure care was provided to prevent pressure ulcer development and urinary tract infection (A395), failed to ensure care planning was initiated and updated with any changes in care for all patients (A396), and failed to ensure it had policies in place to identify, differentiate, and schedule those medications that are time-critical and those that are non-time critical (A405). The cumulative effect of these systemic practices resulted in the facility's inability to ensure that the patients' nursing needs would be met.

Based on medical record review and staff interview, the facility failed to ensure preventive measures were implemented and care was provided to prevent skin breakdown and urinary tract infection for two of 11 medical records reviewed (Patients 1 and 3). The facility had a census of 78.

Findings include:

The medical record of Patient 1 was reviewed on 04/08/13. The patient was admitted on 04/20/12 and discharged on 05/05/12. The patient was 18 years old, five feet ten inches and 95 kilograms. The patient was admitted with a diagnosis of Kyphosis and had a spinal fusion of L1-L3 on 04/20/12. The only skin lesions identified on admission were multiple healing lesions on the arms and chest from scratching. On 04/24/12, the patient had a MRI of the lumbar spine secondary to right lower extremity weakness which showed disc herniation. On 04/25/12, the patient had a L4-L5 laminectomy with decompression of the nerve roots on the right and left. The medical record noted that on 04/27/12 at 8:35 AM that ecchymosis (bruising) was identified on Patient 1's coccyx that the family member stated wasn't there before. On 04/28/12 at 10:13 PM, the nurse noticed a reddish purple area to the patient's coccyx and referred to it as a "bruise from surgery" and paged the physician who would look at it in the morning. On 05/02/12 at 10:40 PM, the nurse noted the coccyx had a circular pink area and open wound about two centimeters by one centimeter and the resident was notified. An order for a Mepilex dressing to the coccyx was received. On 05/03/12 at 1:10 PM the coccyx wound was noted to be excoriated with yellow tissue. On 05/04/12 at 4:20 AM, the coccyx wound was noted to be six and a half centimeters by five and a half centimeters. On 05/05/12 at 8:40 AM, the wound was noted to be two centimeters by two centimeters by 0.3 centimeters. The medical record lacked additional measurements of this wound. The medical record lacked documentation of any wound or incision infection. The medical record lacked documentation that the patient was consistently turned and repositioned every two hours during this hospital stay. The medical record lacked any changes in care provided after the skin breakdown was identified to the patient's coccyx except a dressing change order. The medical record contained orders for bedrest with log roll side to side every 2 hours and as needed from 04/20/12 through 04/22/12. The medical record lacked care planning for turning and repositioning or skin breakdown prevention measures. The medical record lacked documentation of care planning for pressure ulcer management. The medical record contained documentation of a urinary tract infection on 05/02/12 with E coli growth. The medical record lacked care planning for Foley catheter. The medical record lacked documentation at least daily of Foley care. These findings were verified by Staff E and N at the time of discovery.

Staff E was interviewed on 04/08/13 at 5:15 PM and stated that currently there is no policy on the Braden scores and what interventions to implement based on the patient's risk of skin breakdown. Staff E stated that in the fall of 2012 the computerized record was revised to automatically populate a care plan for skin care if the Braden score is below 16. Staff E verified that Patient 1 never had a Braden score below 17 and never had care planning for skin breakdown prevention or pressure ulcer care.

Staff F was interviewed on 04/09/13 at 10:34 AM. Staff F stated that he/she is on the wound care committee. Staff F stated that the Braden Q assessment should be done on admission and daily if the patient is chairfast or bedfast. Staff F stated that the committee is aware that more specific policies regarding skin care are needed (evaluation, treatment, prevention) but are not in place as of yet. Staff F verified that there is no specific policy for the Braden Q and that there is a lot of disconnect among the staff with what the Braden Q scores are and what to do with the information.

Staff B was interviewed on 04/10/13 at 12:25 PM and stated that there was no policy on frequency of Foley care to be completed.

The medical record for Patient 3 was reviewed on 04/09/14. The patient was admitted to the facility on 01/07/13 and was discharged to a rehabilitation facility on 01/29/13. The patient had multiple traumas from a motor vehicle accident and multiple fracture repairs and pinnings. The patient had orders for log rolls every two hours. The patient developed a pressure ulcer to his/her back that was first identified on 01/16/13 that was a stage two and five centimeters by three centimeters. Wound care was initiated. The patient was ordered on bedrest from admission until 01/17/13. The medical record lacked documentation of consistent turning and repositioning every two hours. This was verified by Staff L at the time of discovery.

Based on medical record review and staff interview, the facility failed to ensure all patients had care plans intiated and updated with any changes in care or needs. This affected four of 11 medical records reviewed (Patients 1, 9, 7, and 8). The facility census was 78.

Findings include:

The medical record of Patient 1 was reviewed on 04/08/13. The patient was admitted on 04/20/12 and discharged on 05/05/12. The patient was 18 years old, five feet ten inches and 95 kilograms. The patient was admitted with a diagnosis of Kyphosis and had a spinal fusion of L1-L3 on 04/20/12. The only skin lesions identified on admission were multiple healing lesions on the arms and chest from scratching. On 04/24/12, the patient had a MRI of the lumbar spine secondary to right lower extremity weakness which showed disc herniation. On 04/25/12, the patient had a L4-L5 laminectomy with decompression of the nerve roots on the right and left. The medical record noted that on 04/27/12 at 8:35 AM that ecchymosis (bruising) was identified on Patient 1's coccyx that the family member stated wasn't there before. On 04/28/12 at 10:13 PM, the nurse noticed a reddish purple area to the patient's coccyx and referred to it as a "bruise from surgery" and paged the physician who would look at it in the morning. On 05/02/12 at 10:40 PM, the nurse noted the coccyx had a circular pink area and open wound about two centimeters by one centimeter and the resident was notified. An order for a Mepilex dressing to the coccyx was received. On 05/03/12 at 1:10 PM the coccyx wound was noted to be excoriated with yellow tissue. On 05/04/12 at 4:20 AM, the coccyx wound was noted to be six and a half centimeters by five and a half centimeters. On 05/05/12 at 8:40 AM, the wound was noted to be two centimeters by two centimeters by 0.3 centimeters. The medical record lacked additional measurements of this wound. The medical record lacked documentation of any wound or incisional infection. The medical record lacked documentation that the patient was consistently turned and repositioned every two hours during this hospital stay. The medical record lacked any changes in care provided after the skin breakdown was identified to the patient's coccyx except a dressing change order. The medical record contained orders for bedrest with log roll side to side every 2 hours and as needed from 04/20/12 through 04/22/12. The medical record lacked care planning for turning and repositioning or skin breakdown prevention measures. The medical record lacked documentation of care planning for pressure ulcer management or Foley care.

Staff E was interviewed on 04/08/13 at 5:15 PM and verified that Patient 1 never had care planning for skin breakdown prevention or pressure ulcer care.

Staff N was interviewed on 04/10/13 at 12:22 PM and verified that Patient 1 never had care planning for Foley catheter care.





The medical record review for Patient #9 was completed on 04/09/13. The medical record review revealed the 11 month old patient was admitted to the facility on 04/03/13. The review revealed an emergency department physician note dated 04/03/13 at 7:50 P.M. that stated the patient presented to the emergency department for a chief complaint of productive cough of yellow sputum and greenish discharge of the eye.

Review of a history and physical dated 04/03/13 at 11:26 P.M. stated the parents noted significant increase in amount of respiratory secretions, needed to suction him/her more frequently, gets agitated, and looks like he/she struggles to breath. The history and physical stated he/she and a history of cardiac arrest, was tracheostomy dependent, has cerebral palsy, has epilepsy, had hypoxic-ischemic encephalopathy, has asthma, has developmental delay, and was dependent on a gastric tube for feedings.

The medical record review did not reveal any nursing care plan. On 04/09/13 at 3:14 P.M. in an interview, Staff M confirmed there wasn't any nursing care plan for the patient. On 04/09/13 at 3:14 P.M. in an interview, Staff N said the computer system notifies the nursing staff every 24 hours to create a nursing care plan if none have been. He/she confirmed since the patient had been admitted on 04/03/13, the computer system would have notified the nursing staff at least five times to create a nursing care plan.

The medical record review for Patient #7 was completed on 04/09/13. The medical record review revealed the 15 year old patient was admitted to the facility on 04/07/13. The medical record review revealed a history and physical dated 04/07/13 that stated the patient had transferred into the facility in respiratory failure, seizures, and altered mental status. The history and physical stated the patient was previously healthy with no known medical issues. The history and physical stated on 04/06/13 the patient was walking around and not responding as usual. The history and physical stated later that night he/she was found in her/his chair drooling and incontinent. The history and physical stated the patient was on a ventilator, and listed meningitis as a diagnosis.

On 04/07/13 at 9:44 A.M. the patient was assessed as being bed fast and making only slight changes in body position. At this time he/she was also assessed as having inadequate nutrition. On 04/09/13 at 2:13 P.M. the surveyor observed the patient to continue to be on a ventilator and was making little movement in the bed.

The medical record review did not reveal any nursing care plan to address skin care.

The medical record review did reveal a physician's order dated 04/07/13 at 8:45 A.M. to turn the patient every two hours.The medical record revealed on 04/07/13 at 12:00 P.M. the patient was in a supine position until 8:00 P.M., when he/she was turned onto the right side. The medical record review revealed on 04/08/13 at 8:14 A.M. the patient was in a supine position until 1:09 P.M.

On 04/09/13 at 2:13 P.M. in an interview, Staff M confirmed there wasn't a care plan to address skin care. He/she said the computer system would alert the staff to create one only if the patient had been assessed at risk according to a Braden q scale. He/she said the facility did not have a policy to support this.

On 04/09/13 at 2:13 P.M. in an interview, Staff M said age and weight made no difference in how patients' skin would be assessed for risk of pressure sores. He/she said the Braden q scale would be used for everybody from an eight month old to a 180 pound 18 year old linebacker for the football team. He/she said the facility did not have a policy to support this.

On 04/10/13 at 9:43 A.M. in an interview, Staff I said, "We have problems with detection" of pressure sore risks.

The medical record review for Patient #8 was completed on 04/09/13. The medical record review revealed the six-year-old patient was admitted to the facility on 04/06/13 at 4:32 P.M. The medical record review revealed a history and physical that stated the patient suffered a blunt abdominal trauma after being hit by a car while crossing the road.

The medical record review revealed a nursing care plan dated 04/07/13 that gave "neurological" as a problem statement, with a goal of maintaining a safe environment. The sole intervention listed was "watch closely. "

The medical record review revealed a nursing note dated 04/08/13 at 11:28 P.M. that stated the patient had removed her/his nasogastric tube and was found on the floor. A physician progress note dated 04/09/13 at 6:33 A.M. stated, "he/she fell out of bed. "

The medical record review did not reveal where the care plan reflected an adaptation to the patient's fall, and continued to state, "watch closely. "





21893

Based on interview, medical record review, and policy review, the facility failed to ensure it had policies in place to identify, differentiate, and schedule those medications that are time-critical and those that are non-time critical. This affected two of 11 sampled patients, Patient #9 and Patient #7. The facility's census was 78.

Findings:

The medical record review for Patient #9 was completed on 04/09/13. The electronic medical record review revealed the 11 month old patient was admitted to the facility on 04/03/13. The medical record revealed an emergency department physician note dated 04/03/13 at 7:50 P.M. that stated the patient presented to the emergency department for a chief complaint of productive cough of yellow sputum and greenish discharge of the eye.

Review of a history and physical dated 04/03/13 at 11:26 P.M. revealed the parents noted significant increase in amount of respiratory secretions, needed to suction him/her more frequently, gets agitated, and looks like he/she struggles to breath. The history and physical stated he/she and a history of cardiac arrest, was tracheostomy dependent, has cerebral palsy, has epilepsy, had hypoxic-ischemic encephalopathy, has asthma, has developmental delay, and was dependent on a gastric tube for feedings.

Review of the medication administration record revealed the patient was prescribed an antispasmodic, antibiotic, anti-hypertension, and anti-epileptic medication. The medication administration record did not indicate which medications were time-critical and which were non-time-critical.

The medical record review for Patient #7 was completed on 04/09/13. The medical record revealed the 15 year old patient was admitted to the facility on 04/07/13. Review of the history and physical dated 04/07/13 revealed the patient had transferred into the facility in respiratory failure, seizures, and altered mental status. The history and physical stated the patient was previously healthy with no known medical issue and on 04/06/13 the patient was walking around and not responding as usual. The history and physical stated later that night he/she was found in her/his chair drooling and incontinent. The history and physical stated the patient was on a ventilator, and listed meningitis as a diagnosis.

Review of the medication administration record revealed the patient was prescribed an antiviral, antibiotic, antacid, and antiseizure medication. The medication administration record did not indicate which medications were time-critical and which were non-time-critical.

Review of the facility's policy, "Medication Administration Times Standardization," last reviewed on 01/05/09, stated, "Medication may be administered 30 minutes before or after the scheduled medication time," and did not describe and differentiate time-critical and non-time-critical scheduled medications.

On 04/09/13 at 4:05 P.M. Staff B confirmed the facility does not yet differentiate between time-critical and non-time-critical medications.