HospitalInspections.org

30952

Based on review of medical records, policy and procedures, Alabama Board of Nursing Standards of Practice and interviews it was determined the nursing staff failed to:

1. Have orders for wound care provided.

2. Document specific wound care provided

3. Document wound measurements

4. Document physician notification of a change in skin integument

5. Ensure accurate nutritional risk assessment completion and development of a nutritional plan for an at risk patient.

6. Obtain daily weights as ordered.

This had the potential to affect all patients served by the facility and did affect Medical Records (MR's) # 1, # 4, # 5 and # 6. This affected 4 of 7 medical records reviewed.

Findings include:


Nursing Services Policy and Procedure
Title: Nutritional Screening
Date of Revision: 3/14
Purpose:
" A. To ensure the provision of appropriate medical nutrition therapy to all patients, including nutritional education...
B. To identify patients at nutritional risk and establish the need for further assessment by a registered dietician.
C. To provide timely nutritional intervention for patients identified at nutritional risk by a clinical dietician.
D. To document data pertinent...and develop a nutritional care plan for the individual patient throughout the continuum of care.
Procedure:
A. All inpatients will be screened for possible nutritional risk...by nursing staff.
F. All patients will be monitored by nursing...

A consult should be ordered for adult patients with nutritional risk criteria including BUT NOT LIMITED TO the following:
a. Unintentional weight loss...
d. Patient on Modified Diet (...Cardiac...Diabetic...)
h. Difficulty chewing or swallowing
i. Poor PO intake/Poor appetite

Patients are considered " at nutritional risk" if 2 or more criteria is met..."



Alabama Board of Nursing Chapter 610-X-6
Standards of Nursing Practice

610-x-6-.13 Standards for Wound Assessment and Care

(1)" It is within the scope of a registered nurse or licensed practical nurse practice to perform wound assessments including, but not limited to, staging of a wound and making determinations as to whether wounds are present on admission to a healthcare facility pursuant to an approved standardized procedure..."

(2) " The minimum training for the registered nurse or licensed practical nurse that performs selected tasks associated with wound assessment and care shall include:
(a) Anatomy, physiology and pathophysiology.
(c) Equipment and procedures used in wound assessment and care.
(d) Chronic wound differentiation.
(e) Risk identification.
(f) Measurement of wound.
(g) Stage of wound.
(h) Condition of the wound bed including:
(i) Tissues
(ii) Exudates
(iii) Edges
(iv) Infection
(i) Skin surrounding the wound."

610-X-6-.06 Documentation Standards

(1)" The standards of documentation of nursing care provided to patients by registered nurses or licensed practical nurses are based on principles of documentation regardless of the documentation format.

(2) Documentation of nursing care shall be:
(a) Legible
(b) Accurate
(c) Complete. Complete documentation includes reporting and documenting on appropriate records a patient's status, including signs and symptoms, response, treatments, medications, other nursing care rendered, communication of pertinent information to other health team members, and unusual occurrences involving the patient."


Nursing Services Policy and Procedure
Title: Prevention and Management of Wounds
Date of Revision: 3/14
"...Policy:
2. Assess skin condition at least one time per shift and document. If the... admitting doctor has not given any orders pertaining to wound care the following protocol should be followed:
a. Measure wound
b. Cleanse wound
c. Place a dry dressing on wound
d. Obtain an order within 24 hours regarding wound care
3. Status and condition of pressure ulcers or wounds should be assessed upon admission and at every dressing change. The location, stage, type...length, depth, exudate, odor, presence of necrotic or granulation...and condition of surrounding skin...documented on a daily basis as well as condition of wound edge or every time the nurse changes the dressing.
5. If doctor ordered dressing changes on admission orders should orders should include specific cleaning solution, type of bandage and amount of dressing changes. If dressing changes are not ordered call and verify.
6. Provide wound care as doctor ordered...
7. Chart in patient's record...
12. Patients physician will be notified of any changes in wound."


Nursing Services Policy and Procedure
Title: Wound Care Procedure for Major Wounds
Date Revised: 11/12
" Purpose: To provide guidelines for good technique in doing wound care.
...Procedure:
...W. Document the treatment in the patient's chart with notation of status of wound, drainage, skin integrity, etc."


Nursing Services Policy and Procedure
Title: Management of Trauma Wounds
Date of Revision: 3/14
Purpose: This policy covers the assessment and treatment of patients presenting with abrasions, avulsions, superficial lacerations, puncture wounds...Puncture wounds are small external openings...produced by a penetrating intact skin with sharp or pointed objects.
Policy:
"1. Assess skin condition at least one time per shift or when dressing is changed per doctor order and document. This should include but not limited to:
a. General appearance of the wound
b. Active bleeding
c. Evidence of contamination
d. Degree of swelling and tenderness...
2. Status of abrasions...superficial lacerations, puncture wounds...should be assessed...and orders written with specific cleaning solution, bandage, packing and amount of dressing changes on the care of the wound on admission.
3. Provide wound care as doctor ordered...
4. Chart in patient's record...
6. Patients physician will be notified of any changes in the wound."


Medical Record findings:


1. MR # 1 was admitted to the facility 3/28/14 with a diagnosis of Left Hand Cellulitis.

Review of the 3/28/14 10:30 AM nursing orders included daily weights.

Review of the 3/28/14 patient progress note documentation included a weight of 203 lbs (pounds). There were no weights documented on 3/29/14, 3/30/14 or 3/31/14.

In an interview on 4/2/14 at 10:30 AM with Employee Identifier (EI) # 1, the Director of Nurses, it was confirmed staff failed to perform daily weights as ordered.


2. MR # 4 was admitted to the facility 3/20/14 with diagnoses of Upper Gastrointestinal Bleed and Anemia.

The patient's weight on admission was 120 lbs. (pounds), no height was documented. The 3/20/14 diet orders were for a Regular diet and daily weights ordered.

The Nutritional Screening Form, completed 3/20/14 by the Registered Nurse (RN) included the following information, " CHF (Congestive Heart Failure), HTN (Hypertension), COPD ( Chronic Obstructive Pulmonary Disease), Acute Crohns, Anorexia, Cirrhosis, Anemia, CVA (Cerebrovascular Accident), Dehydration, Cancer, Renal Failure, DM (Diabetes Mellitus); Difficulty chewing or swallowing; Poor PO (oral) intake and/or Poor appetite."

The 3/20/14 nutritional risk screening revealed the patient was considered at nutritional risk as 2 or more criteria were met. There was no documentation that a Registered Dietician referral was made. There was no nursing documentation the patient's nutritional risk status was addressed as a problem with interventions ordered/ implemented and goals achieved.

An interview conducted on 4/2/14 at 10:35 AM with EI # 1 confirmed the the finding above.


3. MR # 5 was admitted to the facility 3/27/14 with diagnoses including Diabetes Mellitus Type II and Left Foot Cellulitis with puncture wound.

Review of 3/27/14 documentation included physician's orders for an 1800 calorie ADA (American Diabetic Association) diet, daily weights and wound care orders with Triple Antibiotic Ointment and dressing.

The 3/27/14 order did not include a frequency the wound care was to be performed or what cleansing solution was to be used prior to antibiotic application. There was no documentation staff attempted to clarify the 3/27/14 wound care order.

Documentation revealed on 3/27/14 a weight of 180 lbs and 170 lbs on 3/28/14. No weights were documented 3/29/14 and 3/30/14.

Review of the 3/28/14 Nutritional Screening Form, completed by the RN included the following information, " CHF, HTN, COPD, Acute Crohns, Anorexia, Cirrhosis, Anemia, CVA, Dehydration, Cancer, Renal Failure, DM." The nutritional screening form did not reflect the physician's order for a Modified Diet, the 1800 ADA diet.

Staff failed to accurately perform MR # 5's nutritional screening. The patient was at nutritional risk, meeting 2 of the required criteria. There was no documented referral for a dietary evaluation as per policy.

Review of the 3/28/14 nurse documentation revealed the following:
4:00 AM; Wound assessment re-evaluated, see Unisex Body Documentation, Site A: left lateral foot local erythema, drainage none, description of wound: dry.
6:45 AM; Wound assessment: See Wound Flowchart. (There was no 3/28/14 6:45 AM flowchart documentation).
3:00 PM; No changes from previous assessment, drainage: none, description dry, no odor.

There was no documentation that triple antibiotic ointment and a dressing was applied 3/28/14. The document for medications administered did not include triple antibiotic ointment and a dressing. The staff failed to include documentation of the size of the involved area to the left foot.

Review of the 3/29/14 nurse documentation revealed the following:
12:01 AM; Wound assessment re-evaluated: See Unisex Body Documentation Site A: location left foot, Notes: 3/28/14 less erythem noted to anterior surface, drainage: none, description of wound: No odor. Dressing: Open to air.
7:00 AM; Wound Assessment: N/A (not applicable).
3:01 PM; Wound Location: See Unisex Body documentation. Site A: Location: Left Foot: Notes: Erythema, Drainage: None. Description of Wound: No odor; Dressing: Open to air.
3:10 PM; Wound Assessment: N/A. Wound Status Assessment: wound assessment re-evaluated.

Further review contained the 3/29/14 hospitalist's documentation which revealed an incision and drainage with splinter removal from the left foot was performed.

The nursing documentation failed to include that wound care was performed 3/29/14. The documentation failed to reveal the size/measurements of the involved area of the left foot.

Review of the 3/30/14 nurse documentation revealed the following:
12:15 AM; Wound Status Assessment: No changes from previous assessment: See Unisex Body Documentation Site A: location left lateral foot, Notes: 3/27/14 slight erythema, no open area: Drainage: none. Description of wound: No odor. Dressing: Open to air."
7:31 AM: Incisions/Dressings: See Wound Flowchart, Open to air; Site A. Location: left foot; Notes: noted on admission small reddened area of left foot. Wound Status Assessment: No changes from previous assessment; See Unisex Body Documentation. Drainage: None. Other type of wound: N/A. Description of Wound: N/A.
9:58 AM: Wound Status Assessment: No changes from previous assessment.

The 3/30/14 nursing documentation failed to include that wound care was provided. The 3/30/14 documentation failed to reveal the size or measurements of the involved area of the left foot.

There was no wound care completed or documented during the stay. Staff failed to document the size of the area of involvement to the left foot.

An interview with EI # 1 on 4/2/14 at 10:40 AM confirmed the above.


3. MR # 6 was admitted to the facility 3/21/14 with diagnoses including Pneumonia and Essential Thrombocytopenia.

Review of the 3/21/14 physician's history and physical documentation revealed MR # 6's had elevated platelets at 823,000 and several ecchymotic areas to bilateral forearms. The patient had a history of a fall 5 days earlier.

Review of the 3/21/14 12:44 PM nursing initial assessment documentation included a right elbow wound, size 2 cm (centimeter) x (by) 1 cm, bloody appearance as scab ripped off while getting into bed. The nurse provided the following care: Cleaned with saline, nonadherent pad applied and covered with tape.

Staff failed to obtain and document orders for the 3/21/14 wound care provided to the right elbow wound according to policy.

Review of the 3/22/14 nursing documentation included the following:
2:49 AM; skin condition was intact, incisions/dressings and wound assessment: N/A (not applicable).
8:20 AM; skin condition was intact, skin tear location, rt (right) elbow with scab on left elbow. Incisions/Dressing: Dry and intact, rt elbow open to air, left elbow (no further documentation).
3:02 PM; Wound Ostomy Flowchart: Other type of wound: skin tear x 2. Both elbows has healed areas on them and when he fell Sunday and scraped the scab off rt elbow. Description of wound: Beefy red granulation tissue. Wound Dimensions (cm): Length; left (elbow wound)1 1/2 x 1; rt (elbow wound) 1/1/4 x 1 3/4 with bandage on rt elbow, cleansed area and reapplied telfa and tape and bandage.
3:08 PM; Dressing: Telfa to rt elbow and left elbow open to air.
3:30 PM; Wound Description: Right hip has large multi-colored bruise.

There were no physician orders for the 3/22/14 wound care. Staff failed
to document the type solution used to cleanse the wound on 3/22/14. There was no documentation the physician was notified when the large multi-colored right hip bruise was discovered. There were no documented measurements for the size of involved area.

Review of the 3/23/14 nursing documentation included the following:
7:41 AM; Skin condition: Abrasion/Laceration, Fragile/Thin. Wound Assessment: N/A; Description of Wound: Smooth red tissue, rt elbow with partial scab and left elbow has scab. Wound Dimensions: Completely closed, left elbow and did not measure right elbow today, measured yesterday and has dressing.
3:00 PM; Description of Wound: Right elbow bandage dry and intact. Left elbow has dry scab. Right hip has large multi-colored bruise. Wound Dimensions: Did not visualize right elbow. Left elbow: Length 2 cm, width 2 cm.

Staff failed to document measurements of the right elbow wound on 3/23/14.

Review of the 3/24/14 nursing documentation included the following:
12:26 AM; Wound Status Assessment: No change from previous assessment.
12:44 AM; Description of Wound: Dsg (dressing) intact to right elbow. Left elbow scabbed over; Wound Dimensions: Did not measure; Dressing: Dry and intact, no changes.
10:12 AM; RT elbow 1 1/2 width; 1 in (inch) (length) completely closed; Left elbow and partial scab has loosed and came loose with telfa. Cleansed and redressed with telfa and gauze.

Staff failed to obtain written orders for wound care performed 3/24/14. There was no documentation of the solution used to clean the left elbow wound. There was no documentation of the of the " right hip large multi-colored bruise " presence.

Review of the 3/25/14 nursing documentation revealed the following:
12:47 PM; Wound assessment re-evaluated, healing and looking better. Cleansed and redressed with telfa. No redness, infection or drainage noted. Wound Dimensions: Did not measure today, measured yesterday. Telfa to right elbow.

Staff failed to obtain written orders for wound care performed 3/25/14. There was no documentation of the solution used to clean the wound. Staff failed to perform a wound assessment every shift as per policy. The 3/25/14 documentation did not include assessment of the right hip large multi-colored bruise.

An interview with EI # 1 on 4/2/14 at 10:50 AM confirmed that staff failed to obtain written wound care orders, document specific wound care provided and perform wound assessments per facility policy.

30952

Based on review of policy and procedure and interview it was determined the facility failed to follow its policy for dishwasher temperature monitoring. This had the potential to negatively affect all patients, staff and visitors served by the facility.

Findings include:


Facility Procedure Title:
Recording of Dishmachine Temperatures
(No date)

"1. Before each use, prepare dishmachine for use...Allow dishmachine to run 10 minutes...to bring water temperature up to proper level...
2. Read temperature gauges...
3. Record temperatures daily on Dishmachine Temperature Log...
Wash Temperature..High...160 degrees F.( Fahrenheit)
Rinse...High (greater than or equal to 180 F).
4. Any inaccurate temperature must be brought to the attention of the Dietary Manager immediately...
8. Dishmachine Temperature Log:
a. To ensure that the wash and rinse temperatures are properly monitored and controlled, a log must be completed by those who are directly involved in the dishwashing process. Entries must be made for each meal.
...d. Actual temperatures must be entered...three times daily...
e. Report temperatures that are less than the required levels..."


A tour of the Dietary department was performed on 3/31/14 at 10:45 AM. The March 2014 Dishroom Temperature Check Sheet revealed no documented temperature entries for the following dates:
3/5/14 AM (morning) meal
3/6/14 Noon and PM (evening) meal
3/8/14 AM meal
3/10/14 and 3/11/14 PM meal
3/13/14 AM and PM meal
3/15/14 AM, Noon and PM meal
3/23/14 AM, Noon and PM meal
3/26/14 AM meal
3/29/14 AM meal
3/30/14 AM meal

An interview, conducted with Employee Indentifer # 4, the Dietary Manager on 3/31/14 at 10:50 AM confirmed dishmachine temperatures had not been documented according to facility policy.