HospitalInspections.org

Based on observation, interview, document review, record review and policy review the Hospital failed to ensure nursing effectively supervised, assessed, and evaluated patient care and failed to ensure nursing staff developed and kept current a nursing care plan for each patient.

The cumulative effect of the facility's failure to provide safe and effective nursing care placed patients at risk for development of wounds, deterioration of current illness, infection and potential for serious harm or impairment.

Findings Include:

1. The hospital failed to ensure nursing supervised and evaluated the nursing care needs for 5 of 7 patients reviewed. (Refer to Tag A0395)

2. The hospital failed to ensure nursing care plans were updated with interventions and/or measurable goals for 6 of 7 patients reviewed. (Refer to Tag A0396)

Based on observation, record review, policy review, document review, and interview the hospital failed to ensure nursing supervised and evaluated the nursing care needs for 5 of 7 patients reviewed (Patient 1, 2, 4, 5, and 6) This deficient practice places the patients at risk for development of wounds, deterioration of current illness, infection, and potential for serious harm and impairment.

Findings Include:

Review of the Hospital's policy titled, "Nursing Documentation," dated 03/28/22, showed "Registered Nurse (RN) assessment will be completed on each patient every 24 hours. This is documented via the daily nursing assessment form and corresponding daily patient care record. Nurse enters information on assessment form, where applicable, as listed on the assessment form. Document narrative notes on the reverse side of the form. Place full signature, date, time, and title on the assessment form. At the end of 24 hours, file the form medical record."

Review of the Hospital's documentation form titled "ADL (activities of daily living) Flowsheet," showed nursing staff must document on personal care provided to patients. There is a place for staff to enter the time care was provided, toileting needs, turning activity, safety, patient's activity, and any other ADLs the patient may require per orders.

Review of the Hospital's policy titled, "Wound Assessment and Reassessment," dated 03/28/22, showed, "The nurse will obtain wound care orders per hospital protocol . . . all wounds will be assessed daily, photographed, and measured weekly, with a debridement or change in wound status. Wound care treatments should be performed per provider orders and documented in the treatment administration record (TAR). Wound care and dressing change times . . . BID (twice daily) once per shift.

Review of the Hospital's policy titled, "Guidelines for Nursing Care," dated 03/28/22, showed, "bedfast patient turned and documented every 2 hours and PRN (as needed) and patient rounding, minimum Q (every) 2 hours."

Review of the Hospital's document titled, "Therapeutic Surface Decision Tree - Pressure Ulcer Care & Prevention," dated 01/2023, showed High Risk Norton and Very High-Risk Norton scores an "Air Force 1000 Mattress," with pulsation therapy.

Review of www.woundcareinc.com showed that a "LAL mattress is a mattress designed to prevent and treat pressure wounds. The mattress is composed of multiple inflatable air tubes that alternately inflate and deflate, mimicking the movement of a patient shifting in bed or being rotated by a caregiver, never leaving the patient in one position for any extended length of time. This action relieves pressure under the body - particularly in parts with less padding, like hips, shoulders, elbows, and heels - and helps ensure proper air circulation, helping to prevent, manage, and treat the occurrence of pressure wounds."

Review of www.mayoclinic.org showed that "heart failure . . . daily weight log . . . If you gain 3 [three] pounds in one day or 5 [five] pounds in two days, call your health care provider." Weight monitoring can help identify fluid retention and early sign of heart failure exacerbations.

Review of the Hospital's policy titled "Nursing Documentation", Revised on 03/28/22, showed, RN Screening Assessment "Pain symptoms: indicate current status of pain control, intensity, and location of pain. If pain is daily, complete the pain comfort assessment guide."

Review of "Lippincott Procedures" provided by the hospital, titled "Closed-Wound Drain Management" showed "Documentation associated with close-wound drain management includes: date and time each time you empty the drain; appearance of the drain exit site, including swelling or other signs of infection any equipment malfunctions subsequent nursing interventions patient's tolerance of the treatment whether the patient has more than one closed-wound drain number assigned to the individual drains drainage information for each site: color, consistency type amount of drainage on the intake and output sheet.


Patient 1

Review of Patient 1's discharged medical record showed a 71-year-old Caucasian female recently diagnosed with melanoma on the left inner upper thigh with multiple satellite lesions. Patient 1 underwent a resection of left thigh melanoma with split thickness skin graft surgery on 03/09/23 and was admitted to RHOP on 03/11/23. Patient 1 developed tachycardia (fast heart rate), leukocytosis (elevated white blood cell count indicating infection), and hypotension (low blood pressure) for which she was transferred back to the acute care hospital on 03/22/23. Patient 1 was readmitted on 03/31/23. Patient 1 had a Negative Pressure Wound Therapy (NPWT) wound vacuum (vacuum dressings and equipment to promote healing in chronic, surgical, and acute wounds) and a Jackson Pratt (JP- A closed suction drain used to remove fluids that build up in areas of your body after surgery) drain to her left thigh.

1. Review of nursing admission assessment dated 03/31/23 at 5:00 PM failed to show documentation of a JP drain present on admission.

Review of Nursing Shift Assessment documentation for the dates 03/31/23, 04/01/23, 04/03/23, 04/04/23 showed documentation of a JP drain. However, there was no documentation to show assessment and monitoring the JP drain exit site, drain output or description of the drainage.

2. Review of the transferring facility's discharge orders dated 03/31/23 showed scheduled postoperative follow up on 04/03/23. The discharge orders did not include how to proceed with the wound vacuum or the suction setting for the wound vac.

The record failed to show nursing staff contacted the surgeon to clarify the wound care orders.

During an interview on 04/19/23 at 9:11 AM, Staff L, RN stated that when she came on shift the evening of 04/02/23, the wound vac had no suction per the Staff Z Licensed Vocational Nurse (LVN). Staff Z stated that they had been changing the chux under the patient because Staff Z thought the foley catheter was leaking. Staff L, RN stated that the wound vac was not functioning properly. Staff L, RN stated that she called the charge nurse first, then the wound care team, and then called Staff D, MD. Staff L, RN stated that she could not locate the surgeon's contact information, so she did not call him/her.

Although Staff L, RN stated that she could not locate the surgeon's contact information, the clinic follow-up number, and contact information for the on-call physician was included on the transferring facility's discharge orders dated 03/31/23.

Review of Staff L, RN nursing documentation dated 04/02/23 at 9:00 PM showed "Charge Nurse (CN) together with this writer consulted with wound nurse and Staff D, MD regarding Left thigh wound treatment, advised to continue with wet to dry dressing application until NPWT supplies available, wound noted with copious amount of serous drainage, patient tolerated dressing change well."

The record failed to show any documentation that the day shift nurse Staff Z, LVN, Staff L, RN, the charge nurse and/or the wound care nurse attempted to notify the surgeon that the patient's wound vac was not working on 04/02/23.

Review of Patient 1's clinic office visit note dated 04/03/23 showed "Order Comments, No dressing change to the left thigh surgical split thickness skin graft. This will be changed at the clinic on Wednesday 04/05/23. Cover donor site with a dry abdominal pad daily and as needed (PRN) as soiled."

Review of Staff I, LVN nursing documentation dated 04/03/23 4:36 PM showed "Spoke to the NP (nurse practitioner) of [hospital] where the patient did her skin graft and stated that nobody kept in touch with them this weekend regarding the patient not having the wound vac in place. I explained to her that the night shift nurse reported to me this morning and she stated that we ran out of cannister.

During an interview with on 04/19/23 at 10:00 AM Staff I, LVN stated that Patient 1 had an appointment with wound care on 04/03/23 and we sent her out. Staff I stated that the nurse practitioner called while the patient was there. Staff I stated that the nurse practitioner was a little upset because no one called them and notified that the wound vac was not on since the evening of 04/02/23.

Review of Staff E, Wound Care Nurse, documentation dated 04/04/23 at 8:50 AM showed "Wound care consult not necessary at this time due to graft and donor site to be managed by surgeon's office only"

3. Review of Staff G RN nursing documentation dated 04/04/23 at 9:35 AM showed Patient 1 was noted to have labored breathing with intercostal retraction (inward movement of the skin between the ribs). Patient 1's Glasgow Coma Scale (GCS- a system to "score" or measure how conscious a person is) was 8 (Severe: GCS 8 or less, Moderate: GCS 9-12, Mild GCS 13-15). Patient only responds weakly with head nod or shake. No oozing noted to left thigh wound. Meds held due to patient's status. Patient unable to swallow medications. Husband in attendance. Attempted to contact Staff D, MD unsuccessfully. Left a voicemail awaiting callback.

Review of subsequent documentation dated 04/04/23 at 11:00 AM, 11:28 AM and 11:35 AM "Pt breathing still labored with intercostal retraction. Pt turn head to voice but does not open eye. Pt nods and shake head to response. Saturation of Peripheral Oxygen (SPO2) 95%, Heart Rate (HR) 127. Registered Respiratory Therapist (RRT) contacted and evaluated pt. Pt placed on 6 Liters (L) O2 (oxygen) via simple facemask for comfort. Husband by bedside. Husband requested pt to be transferred to a regional referral center for clinical trial and Emergency room (ER) evaluation." Staff D, MD, case manager (CM), nurse manager and charge nurse informed of patient's decision. 911 called and Patient 1 transferred to the acute care hospital.

During an interview on 4/18/23 at 10:58 AM Patient 1's spouse stated that during the second admission to RHOP Patient 1 got progressively worse. Patient 1 spouse stated that when the patient went for her appointment on 04/03/23 the nurse practitioner was upset because the wound vac had stopped working on Saturday and no one RHOP notified the office that the wound vac was not working properly. Patient 1's spouse stated that the Social worker said "you have three choices, make your spouse an DNR, chose hospice or chose another hospital.


Patient 2

Review of Patient 2's current medical record shows a 60-year-old admitted on 3/31/23 with an admitting diagnosis of Acute/subacute bilateral hemispheric (both sides) and cerebellar cerebral vascular accident (strokes). Patient 2 has a medical diagnosis of hypertension (HTN), Diabetes Mellitus (DM II), diastolic cardiomyopathy (heart chambers are enlarged), Atrial Fibrillation (A Fib) (irregular and often very rapid heart rhythm) on anticoagulation (blood thinner), bicuspid aortic valve( two cusp or flaps in the heart valve) with moderate aortic stenosis (aortic valve narrows and blood cannot flow normally), End stage Renal Disease (ESRD) with IgA nephropathy (kidney disease that occurs when an antibody called immunoglobulin A builds up in your kidney) on hemodialysis - initiated Jan 2023, Monoclonal Gammopathy of undetermined significance (MGUS)(abnormal protein in your blood), Chronic Obstructive Pulmonary Disease (COPD), peptic ulcer disease.

1. Review of the CNA document titled "ADL Flowsheet" showed 21 occurrences between the dates of 04/04/23 to 04/17/23 that Staff H CNA and Staff J CNA signed Patient 2's flowsheet prior to the time of service.

During an interview on 04/20/23 at 2:00 PM Staff C, CNO confirmed expectation that CNAs should complete care every two hours and document on even hours. Expectation is that the CNAs document in real time (actual time task completed) or by the end of the shift. There should not be any pre-documentation in the note. Signature time should not be before the time of service.


Patient 4

Review of Patient 4's current medical record showed that Patient 4 was admitted on 03/27/23 at 5:40 PM for treatment after displaying weakness and decline of physical capabilities due to being left in bed at his long-term care nursing facility. Patient 4 has a traumatic brain injury from a gunshot wound five years ago.

1. Review of Patient 4's "Initial Admission Assessment," dated 03/28/23 at 5:46 AM, showed Staff T, Registered Nurse (RN) documented, "No" to the question, "Does the patient have any wounds/incisions?" Further review showed Patient 4's Norton Pressure Injury Risk Score (Norton rating scoring- assesses the patients pressure sore risk; less than 10 Very High Risk, 10 to 14 High Risk, 14 to 18 medium risk and above 18 low risk) was 14, indicating high risk to develop pressure injury.

Review of Patient 4's "History and Physical," dated 03/28/23 at 10:00 AM, showed "Skin P/W/D [Pink, warm, dry].

Review of Patient 4's "Interdisciplinary Notes," dated 03/30/23, showed, Patient 4 had no wounds, he was receiving physical therapy, and was dependent on staff to roll side to side from lying on back.

Review of "PT (Physical Therapy) Assessment," dated 04/10/23 at 11:39 AM, showed, " ...Pt's brief saturated upon arrival, increased time spent doffing/donning new brief, pt initiates rolling well but extra help is needed to complete. Nurse manager notified about consistently soiled brief, bedding, and clothes. Frequent checks by nursing staff is recommended due to pt unable to verbalize soiled belongings."

Review of a document titled, "Tissue Analytics," dated 04/14/23 at 9:45 AM, showed that Patient 4 had a wound on the right buttock that was not present on admission. The wound was 1.51 centimeters (cm) by .81 cm. The wound was a .5 cm in depth. Further review showed the wound had a small amount of drainage. Review of the photo of Patient 4's wound dated 04/14/23 at 9:45 AM, showed an oblong wound that was yellow in the center, red along the edges, and what appears to be scarring or pink skin around the wound.

Review of "Consultation Note," dated 04/14/23 at 2:03 PM, showed Staff N, Doctor of Osteopathy (DO), documented, "The patient is being evaluated for right gluteal unstageable pressure ulceration . . . The right gluteal area has an unstageable pressure ulceration with fibrin changes a rim of granulation no induration or signs of infection ... Plan: The patient will have Silvadene Xeroform adhesive foam placed the right gluteal region twice daily and p.r.n. [as needed] soilage. The patient will have a low air loss (LAL) mattress placed to further offload this area, boots to offload the feet heels and maximize nutritional support."

Review of Patient 4's nurse assessments, completed once each shift, from 03/27/23 to 04/13/23 failed to show documentation of the wound on his right buttock.

Review of the "TAR," dated 04/14/23 to 04/17/23 showed that wound care was not documented on 04/16/23 during the evening hours. The previous wound care occurred at 9:40 AM on 04/16/23 and was not completed again until 04/17/23 at 6:10 AM.

During an interview on 04/18/23 at 10:59 AM, family member (F1) of Patient 4 stated that she noted the wound while nursing staff were assisting Patient 4 with changing his depends when she saw blood on the depends. F1 stated that Patient 4 cannot turn himself in bed. F1 stated that he can grab the bar but requires help with the full turn.

During an interview on 04/18/23 at 12:50 PM, Staff B, CEO, stated that because they found the wound while he (Patient 4) was inpatient it's considered a hospital acquired pressure ulcer. He (Patient 4) got it after sitting in a chair for 6 - 8 hours when he was sent out to get his jpeg tube placement.

During an interview on 04/19/23 at 3:14 PM, Staff B, CEO stated that the wound care nurse reviews every new patients initial nursing assessment and reviews the Norton score. Staff B stated that depending on the score, the wound care nurse can order an air mattress, Q2 repositioning, and consult with physical therapy if a special chair cushion is needed.

During an interview on 04/19/23 at 3:36 PM, Staff V, physical therapy assistant (PTA) stated that she had noted that Patient 4's brief was saturated several times when they arrived to conduct exercises and the need to change Patient 4 cut into their scheduled time. Staff V stated that she has noticed that patients who are unable to communicate their needs or may not be aware that they have had an accident are usually the patients that are soiled when she arrives and that she felt that it was because the patient cannot express their needs. Staff V stated that she was the primary PTA for Patient 4 and she was unaware that Patient 4 had a wound on his bottom. Staff V stated that max assist patients should be shifted every two hours. Staff V stated that Patient 4 is not able to turn on his own. Staff V stated that it is standard care for total assist patients to be rotated between bed and chair every two hours.

During an interview on 04/19/23 at 2:19 PM, Staff R, Medical Doctor (MD) and Medical Director, stated that he expects his staff to conduct and address all areas of the initial nursing assessment, including a skin assessment, upon admission.

2. Review of "Free Text Note," dated 04/12/23 showed "Patient has appointment for peg tube placement on 04/13/23."

Review of the "TAR" showed that no incision care, drainage care, or checks were being completed for the surgical site.

3. During an observation on 04/20/23 at 12:45 PM, Patient 4's right foot showed the big toe and middle toe nails to be thick, yellow, and brown in color with some white areas. The nail of the big toe appears to be growing upward in thickness and appears to be pulling away from the bed of the toe. On top of the first toe on the right foot, next to the big toe, was a small red sore forming.

Further observation showed that all small toes on the left foot had nails that grew past the top of the toe and curled down under the front of the toes. Closer observation of Patient 4's big toe on the left foot showed that the nail had fallen off. During an interview at the time of the observation, F1 stated that Patient 4 was in a lot of pain and that it must be affecting his rehabilitation. F1 stated that Patient 4 has a large dry spot on his left heel that she's been trying to soften up. F1 stated that she asked the nurses to trim Patient 4's toenails or call a podiatrist, but they stated that they couldn't do that.

The hospital failed to provide requested care that was causing Patient 4 pain and interfering with the rehabilitation Patient 4 was receiving. The hospital failed to assist Patient 4 with a consult of a podiatrist (a physician that specializes in foot care) at the patient's expense.

4. Review of Patient 4's "Nursing Plan of Care," showed "[Patient 4] will receive optimal care from the CNA (certified nurse aides). ADL flowsheet every 2 hours ..."

Review of nursing staff's every two-hour documentation from 03/27/23 at 9:18 PM to 04/17/23 at 8:43 AM, primarily completed by CNAs (certified nurse aides) showed the patient repositioned himself 100 times.

Further review showed that repositioning was not completed by staff on the following dates:

1. Two repositioning opportunities were missed on 03/28/23.
2. Six repositioning opportunities were missed on 03/29/23
3. Two repositioning opportunities were missed on 03/31/23
4. Five repositioning opportunities were missed on 04/01/23
5. One repositioning opportunity was missed on 04/03/23
6. Two repositioning opportunities were missed on 04/04/23
7. Three repositioning opportunities were missed on 04/05/23
8. Five repositioning opportunities were missed on 04/07/23
9. Three repositioning opportunities were missed on 04/08/23
10. Five repositioning opportunities were missed on 04/09/23
11. Two repositioning opportunities were missed on 04/10/23
12. Two repositioning opportunities were missed on 04/12/23
13. Three repositioning opportunities were missed on 04/13/23
14. Two repositioning opportunities were missed on 04/14/23
15. Two repositioning opportunities were missed on 04/15/23
16. Four repositioning opportunities were missed on 04/16/23

Review of the "Treatment Administration Record," showed that every 2 hours (Q2) repositioning was added on 04/14/23.

Staff P, RN, documented on 04/16/23 at 8:19 PM that she repositioned Patient 4. Staff P did not document repositioning again until 04/17/23 at 12:07 AM, four hours later.

Further review showed that Staff P, RN documented that repositioning was completed at 9:40 AM for the 8:00 AM and 10:00 AM scheduled repositioning.

On 04/15/23 Staff Q, LVN, documented that the scheduled repositioning for 8:00 AM, 10:00 AM and 12:00 PM were completed at 11:11 AM.

During an interview on 04/18/23 at 2:04 PM, Staff F, CNA, stated that she is required to document every two hours and that repositioning is required every two hours. Staff F stated that they do not reposition as much during the day because the patient is up in a chair. Staff F stated that Patient 4 cannot turn on his own. Staff F stated that repositioning is not needed if the patient is on an air mattress because it shifts them every two to three minutes.


Patient 5

Review of Patient 5's discharged medical record showed that Patient 5 was admitted for rehabilitation of a left ankle fracture on 12/21/22 at 4:29 PM. Patient 5 had recent sigmoid colectomy with ileorectal anastomosis (in this surgery, after the colon and rectum are removed, the small intestine is connected directly to the anus) on 12/14/22. Further review showed that Patient 5 has an extensive medical history including congestive heart failure (a disease that affects pumping action of the heart muscle that causes fatigue and shortness of breath and fluid to build up in the lungs), history of heart attack (when the heart stops), pacemaker (device that is implanted in the chest to help control the heartbeat), state 3 kidney disease (loss of kidney function), high blood pressure and high cholesterol.

1. Review of Patient 5's "ADL [Activities of Daily Living] Flowsheet," showed that two-hour patient rounding checks were inconsistent with the "Nursing Active Plan of Care" intervention of completing the ADL flowsheet every 2 hours for the following dates:

On 12/21/22 at 8:00 PM, Staff LL, CNA, documented she completed her 2-hour ADL checks three hours after the last check at 5:00 PM.

On 12/22/22 at 12:00 PM, Staff MM, CNA, documented she completed her 2-hour ADL checks, nine hours, and two minutes after the last check at 2:58 AM.

On 12/22/22 at 10:00 PM, Staff NN, CNA, documented she completed her 2-hour ADL checks, six hours after the last check at 4:00 PM.

On 12/23/22 at 7:00 AM, Staff OO, CNA, documented she completed her 2-hour ADL checks, three hours, and 20 minutes after the last check at 3:40 AM.

On 12/23/22 Staff OO, CNA, documented at 12:34 PM that she completed the 11:00 AM, 1:00 PM, and 3:00 PM ADL checks, documenting cares she has not yet provided to Patient 5.

On 12/23/22 at 8:00 PM, Staff PP, CNA documented that she completed her 2-hour ADL checks, five hours after the previous check at 3:00 PM.

2. Review of Patient 5's "Vital Signs," showed that Staff KK, CNA, documented Patient 5's weight as 72 kilograms (kg) (158.7 pounds) on 12/21/22 at 4:45 PM. Staff KK, recorded another weight measurement at 5:04 PM, the same date as 75.3 kg (166 pounds).

Staff KK failed to document notification of the weight change to the RN.

Review of Patient 5's physician order's showed there was no order for daily weights. The nursing staff failed to follow up with the physician regarding an order for daily weights and failed to establish a plan of care for managing Patient 5's congestive heart failure.

3. Review of the Hospital's document titled, "Grievance Log," showed that on 03/20/23, family member of Patient 5, F2, called to report concerns on 03/16/23. The hospital noted that they returned the call on 03/28/23. F2 reported that on the evening of 12/23/22, Patient 5 called her (F2) and reported that he was having chest pain, felt that he wasn't going to make it and wanted 911 called. F2 explained in her grievance that there was a delay in getting Patient 5 the care that he needed.

Review of nursing documentation by Staff BB, RN dated 12/23/22 at 7:48 PM showed "Notified by the charge nurse that the patient was complaining of chest pain. The patient stated that the pain starts from the middle of the chest and goes towards the diaphragm. Denied radiating to the shoulder's arms or to the back. Vital signs obtained and were documented B/P 148/78, P 80, R 18, T 98.9 and O2 95% on RA. Patient had green bile emesis small amount. Abdomen auscultated; No bowel sounds present. Abdomen firm and distended. Patient stated that he had abdominal pain and chest pain on and off the whole day. Phone call made to Staff QQ MD at 8:10 PM notified of patient's vomiting green emesis with and complaining of pain from the chest to the diaphragm and absent bowel sounds. Order received to send the patient to an acute care hospital for further evaluation and treatment. Patient 5 was transported by EMS to the acute care facility at 8:48 PM.

During an interview on 04/26/23 at 3:45 PM, F2 stated that on 12/21/22 Patient 5 expressed he wasn't feeling well and was crying and felt that nobody was listening to him. On 12/22/22, Patient 5 informed her that he was worried he was not going to meet his rehabilitation goals because he wasn't feeling well. F2 stated that Patient 5 kept F2 on the phone for 45 minutes and Patient 5 felt that staff were not listening to him. F2 said that by Friday 12/23/22, at noon, Patient 5 called he sounded ill and wanted to go back to [acute care hospital] because something was wrong. F2 stated she attempted to call the hospital several times and the desk person would transfer her to the charge nurse's phone. F2 stated that she left a message and continued to try calling but nobody ever answered the charge nurse phone. F2 stated that at around 5:00 PM Patient 5 called again and said that he didn't think he was going to make it and had been telling staff to call 911 all afternoon. At 8:00 PM, F2 stated she noticed a change in Patient 5's voice and became very stern with the staff. The nurse stated she would have to call the physician for an order to call 911. F2 stated that at about 8:20 PM they finally called the ambulance. F2 stated that when the EMTs assessed him and his vitals, they stated he had to the acute care hospital. F2 stated that Patient 5 had a blockage and fluid was backing up into his cavity and going into his lungs. F2 stated that they took two to 2.5 liters of fluid off Patient 5. F2 stated the hospital failed Patient 5.

Hospital nursing staff failed to respond to Patient 5's complaints of not feeling well and chest pain in a timely manner, resulting in Patient 5 feeling no one was listening to his concerns resulting in a delay of transfer to the acute care hospital.


Patient 6

Review of Patient 6's medical records showed that Patient 6 was admitted on 04/10/23 for rehabilitation after a fall. Patient 6 has weakness and can tolerate standing for only 15 seconds. Patient 6 uses a wheelchair and is moderate to max assist for transfers. Patient 6 has a history or uremic myopathy (muscle abnormalities causing weakness and muscle loss due to high uric acid levels in the blood), non-traumatic rhabdomyolysis (when muscles are severely injured or inflamed), uncontrollable hypertension (high blood pressure), and fictitious disorder (a serious mental disorder in which someone deceives others by appearing sick by purposely getting sick or by self-injury). Patient 6 tested positive for amphetamine (medication used to treat attention deficit disorder) and fentanyl (medication used to relieve severe ongoing pain) use; however verbally denies. Patient 6 has a history of inserting foreign objects into his rectum which resulted in multiple admissions to emergency department (ED) for retrieval of items.

1. Review of Patient 6's "History and Physical," dated 04/10/23 showed, current functional status "He will require assistance with mobility and self-care, assistance with eating, grooming, showering, bathing, and all other ADLs."

Review of Patient 6's admission "Norton Pressure Injury Risk Scores" dated 04/10/22 showed that Patient 6's Norton score was 16 (Norton rating scoring- assesses the patients pressure sore risk; less than 10 Very High Risk, 10 to 14 High Risk, 14 to 18 medium risk and above 18 low risk).

Review of Patient 6's Norton Pressure Injury Risk scores for dates 04/11/23 to 04/19/23 showed that Patient 6's Norton score ranged between 15 to 20. Patient 6 was at low to medium risk for pressure injuries.

During an observation on 04/19/23 at 7:19 PM, Staff Y, RN, was completing a nurse assessment with Patient 6. During the assessment Staff Y was not observed completing a skin assessment or asking Patient 6 if he had any new wounds or rash that needed to be addressed. Staff Y was observed listening to Patient 6's heart under shirt without lifting the shirt to view Patient 6's skin.

Review of Patient 6's "Nurse Assessment," dated 4/19/23 at 7:30 AM showed that Staff Y, RN documented that Patient 6's skin was warm and pink. Staff Y documented that Patient 6 does not have any wounds.

During an interview on 04/20/23 at 9:32 AM, Staff AA, Charge Nurse (CN), stated that skin assessments look the same for the initial nurse assessment and the nurse shift assessments. Staff AA stated that the expectation is that the patient's skin is assessed during the shift assessments. Staff AA stated that the nurse should be asking the patient during the assessment if they have a rash, sore, or any wounds.

Based on record review, policy review, and interview, the hospital failed to ensure the nursing care plan was updated with interventions and/or measurable goals for 6 of the 7 patients (Patient 1, 2, 3, 4, 5 and 6) reviewed. Failure to keep the nursing care plans current has the potential for care needs to not be identified or implemented which can delay the patients' recovery and cause potential harm, or impairment.

Findings Include:

Review of the Hospital's policy titled, "Nursing Documentation," dated 03/28/22, showed, "The nursing services department will provide for a uniform method of documentation that is in compliance with [accrediting organization] standards and federal/state regulation . . . individual plan of care will be completed by RN [nurse] on admission. Nursing objectives may relate to actual or potential functional patient problems. A nurse notation will be entered on the patient care record each shift. An entry will be documented on each item that is pertinent to the patient's condition/care . . . care plan: list and functional patient problems requiring intervention by nursing staff."

Review of the Hospital's policy titled, "Care Plan," dated 03/28/22, showed "The purpose of this policy is to establish guidelines for providing individualized patient care that is multidisciplinary, consistent, coordinated, and high quality . . . The care plan for each individual patient shall be coordinated with his/her medical provider plan of care and will indicate what care is needed and how it can be best achieved. Procedure: care plan is initiated by an RN upon admission. The patient and family will be included in the development of the care plan. The care plan will include the identified patient problems, the goals to work toward and the interventions to be utilized. Care plans are reviewed and updated with any changes as needed by appropriate disciplines. The care plan will also serve as the interdisciplinary plan of care and will be discussed in IDT [interdisciplinary team] weekly and updated by appropriate disciplines. All clinical disciplines must review their specialty areas and update as needed to maintain current patient status needs/interventions. Sign/Date all updated entries.


Patient 1

Review of Patient 1's discharged medical record showed a 71-year-old Caucasian female recently diagnosed with melanoma on the left inner upper thigh with multiple satellite lesions. Patient 1 underwent a resection of left thigh melanoma with split thickness skin graft surgery on 3/9/23 and was admitted to RHOP on 03/11/23. Patient 1 developed tachycardia, leukocytosis, and hypotension for which she was transferred back to the acute care hospital on 03/22/23. Patient 1 was readmitted to rehab facility on 03/31/23. Patient has a Negative Pressure Wound Therapy (NPWT) wound vacuum (vacuum dressings and equipment to promote healing in chronic, surgical, and acute wounds) to left thigh.

Review of document titled "Plan of Care" dated 03/31/23 showed an active problem list of 1. CNA daily plan of care. 2. Nursing daily Plan of care. The facility included goals but failed to show documentation of a long-term goal or short-term goal and that the goals are observable and measurable.

On 04/01/23 "Plan of Care" showed an active problem list 1. Impaired mobility. The Plan of Care failed to show documentation a short-term goal.

On 04/02/23 "Plan of Care" showed an active problem list 1. Alteration in Skin integrity includes goals. The Plan of care failed to show documentation of interventions.


Patient 2

Review of Patient 2's current medical record shows a 60-year-old admitted on 3/31/23 with an admitting diagnosis of Acute/subacute bilateral hemispheric (both sides) and cerebellar cerebral vascular accident (stroke). Patient 2 has a medical diagnosis of hypertension (HTN), Diabetes Mellitus (DM II), diastolic cardiomyopathy (heart chambers are enlarged), Atrial Fibrillation (A Fib) (irregular and often very rapid heart rhythm) on anticoagulation, bicuspid aortic valve( two cusp or flaps in the heart valve) with moderate aortic stenosis (aortic valve narrows and blood cannot flow normally), End stage Renal Disease (ESRD) with IgA nephropathy (kidney disease that occurs when an antibody called immunoglobulin A builds up in your kidney) on hemodialysis - initiated Jan 2023, Monoclonal Gammopathy of undetermined significance (MGUS - abnormal protein in your blood), Chronic Obstructive Pulmonary Disease (COPD), peptic ulcer disease.

Review of document titled "Plan of Care" dated 03/31/23, showed an active problem list of 1. CNA Daily Plan of Care, 2. Nursing Daily Plan of Care 3. Risk for Falls; Goal; Patient 2 will remain free of falls during his hospitalization. The Plan of Care failed to show documentation of a short-term goal.

The 04/01/23 "Plan of Care" showed an active problem list of 1. Impaired Gas Exchange. 2. Impaired Mobility. Goal: Long term goals Return to prior level of functioning. The Plan of Care failed to show short term goals.

The 04/05/23, "Plan of Care" showed an active problem list of 1. Ineffective Airway clearance. The Plan of Care failed show short-term goals.

The 04/14/23 "Plan of Care" showed an active problem list of Alteration in Elimination. The Plan of care failed to show documentation of interventions.

Patient 3

Review of Patient 3's current medical record showed that Patient 3 was admitted on 04/06/23 at 6:37 PM for rehabilitation from a small acute to subacute occipitotemporal infarction (stroke) after experiencing altered mental status and blurry vision.

Review of Patient 3's "Interdisciplinary Notes," dated 04/07/23 at 5:21 PM, showed that Staff D, MD, documented "monitor weight closely on a daily basis."

Review of Patient 3's "Dietician Assessment," dated 04/11/23 at 1:37 PM, showed "monitor PO (by mouth) intake, weight, d/c [discharge] needs, and POC [plan of care]."

Review of Patient 3's "Physician Orders," showed that daily weights were not added to the treatment administration record.

Review of Patient 3's "Vital Signs," dated 04/06/23 to 04/17/23 showed one weight recorded on 04/06/23 at 10:10 PM. It was documented that Patient 3 weighed 59.87 kg (131.83 pounds).

Review of Patient 3's "Plan of Care," dated 04/06/23 showed "Nursing Daily Plan of Care did not have any short- or long- term goals for Patient 3. Further review showed that Patient 3 did not have any goals or interventions addressing his weight and monitoring his weight daily, as recommended by the physician.

Patient 4

Review of Patient 4's current medical record showed that Patient 4 was admitted on 03/27/23 at 5:40 PM for treatment after displaying weakness and decline of physical capabilities due to being left in bed at his long-term care nursing facility. Patient 4 has a traumatic brain injury from a gunshot wound five years ago.

Review of Patient 4's "Plan of Care" dated 03/27/23 showed problem 1: "CNA [certified nurse aide] daily plan of care" with the goal "[Patient 4] will receive optimal care from the CNA; [2] "Goal: [Patient 4] will receive optimal care from the RN/LPN/LVN . . . [4] "Goal: achieve maximal independence in ADLs . . . [6] Decrease pain and demonstrate pain relief strategies . . . "

The Plan of Care failed to identify short- and long-term, measurable goals.

Further review showed "Problem 5: Impaired Gas Exchange." The Plan of Care failed to show any goals for Impaired Gas Exchange.

During an observation on 04/20/23 at 12:45 PM, Patient 4's right foot showed the big toe and middle toe nails to be thick, yellow, and brown in color with some white areas. The nail of the big toe appears to be growing upward in thickness and appears to be pulling away from the bed of the toe. On top of the first toe on the right foot, next to the big toe, was a small red sore forming.

Further observation showed that all small toes on the left foot had nails that grew past the top of the toe and curled down under the front of the toes. Closer observation of Patient 4's big toe on the left foot showed that the nail had fallen off. During an interview at the time of the observation, F1 stated that Patient 4 was in a lot of pain and that it must be affecting his rehabilitation. F1 stated that Patient 4 has a large dry spot on his left heel that she's been trying to soften up. F1 stated that she asked the nurses to trim Patient 4's toenails or call a podiatrist, but they stated that they couldn't do that.

Review of Patient 4's Plan of Care failed to include the need for foot care on the problem lists.

Review of "Free Text Note," dated 04/12/23 showed "Patient has appointment for peg tube placement on 04/13/23."

Review of Patient 4's Plan of Care failed to include the need for enteral feedings or surgical incision care following the placement of the peg tube on the problem list.


Patient 5

Review of Patient 5's discharged medical record showed that Patient 5 was admitted for rehabilitation of a left ankle fracture on 12/21/22 at 4:29 PM. Patient 5 had recent sigmoid colectomy with ileorectal anastomosis (in this surgery, after the colon and rectum are removed, the small intestine is connected directly to the anus) on 12/14/2022. Further review showed that Patient 5 has an extensive medical history including congestive heart failure (a disease that affects pumping action of the heart muscle that causes fatigue and shortness of breath and fluid to build up in the lungs), history of heart attack (when the heart stops), pacemaker (device that is implanted in the chest to help control the heartbeat), state 3 kidney disease (loss of kidney function), high blood pressure and high cholesterol.

Review of Patient 5's "Plan of Care," dated 12/22/22 showed an active problem of "Impaired Skin Integrity" an intervention placed for wound care included "Dietary consult to ensure adequate nutritional intake to promote healing."

Review of Patient 5's medical record showed that a dietary consult was not obtained and did not consider Patient 5's post-surgical dietary needs after his colectomy with ileorectal anastomosis.

Patient 5's "Plan of Care" initiated on 12/22/22 failed to include a nursing care plan with goals and interventions for managing Patient 5's Congestive Heart Failure (CHF).


Patient 6

Review of Patient 6's medical records showed that Patient 6 was admitted on 4/10/23 for rehabilitation after a fall. Patient 6 has weakness and can tolerate standing for only 15 seconds. Patient 6 uses a wheelchair and is moderate to max assist for transfers. Patient 6 has a history or uremic myopathy (muscle abnormalities causing weakness and muscle loss due to high uric acid levels in the blood), non-traumatic rhabdomyolysis (when muscles are severely injured or inflamed), uncontrollable hypertension (high blood pressure), and fictitious disorder (a serious mental disorder in which someone deceives others by appearing sick by purposely getting sick or by self-injury). Patient 6 tested positive for amphetamine (medication used to treat attention deficit disorder) and fentanyl (medication used to relieve severe ongoing pain) use; however verbally denies. Patient 6 has a history of inserting foreign objects into his rectum which resulted in multiple admissions to emergency department (ED) for retrieval of items.

Review of Patient 6's "Interdisciplinary Notes," dated 04/11/23 at 12:09 PM, Staff CC, Occupational Therapist Registered (OTR), documented, "Pt primarily limited by inconsistency in report of history/PLOF, strength assessment, & functional mobility/performance. Pt appropriate for high fall precautions with poor safety awareness & insight into deficits with need for assistance for transfers & functional mobility but refusing alarms at this time. Pt demos good progress but limited by psych behaviors affecting motivation for standing/functional activity very self-directed in caregiving/therapy participation."

Review of Patient 6's "Plan of Care," dated 04/10/23 showed "[Patient 6] will receive optimal care from the RN, LPN, LVN by 04/24/23. Interventions include . . . [3] assessment/reassessment when administering pain medication/analgesics and/or other alternative interventions."

The care plan failed to list alternative interventions to address Patient 6's pain.

Further review showed that the plan of care failed to address the safety needs due to history of placing foreign objects into his rectum, failed to address Patient 6's psychological needs, failed to address Patient 6's uncontrollable hypertension, and failed to provide short- and long-term goals that are measurable to determine Patient 6's progress.