HospitalInspections.org

Based on observation, interview, record review and policy review the facility failed to:
- Consistently take photos of patients' wounds/pressure ulcers (injury to the skin and/or underlying tissue usually over a bony area of the body) upon admission, every Wednesday ("Wound Wednesday" - day staff are expected to take photos and measurements (length, width and depth) of patients' wounds/pressure ulcers) and prn (as needed) for five (#19, #20, #40, #42 and #27) out of five current patients reviewed and for one (#39) out of one discharged patient reviewed with wounds/pressure ulcers. Refer to A-0395 for additional information.
- Consistently document patients' wounds/pressure ulcers that included a description, measurements, location and condition of surrounding tissue upon admission, every Wednesday and prn for for five (#19, #20, #40, #42 and #27) out of five current patients reviewed and for one (#39) out of one discharged patient reviewed with wounds/pressure ulcers. Refer to A-0395 for additional information.
- Follow physician orders for one (#20) out of one current patient observed during dressing change when staff applied tape to his skin. Refer to A-0395 for additional information.
- Follow the facility's policy, "Tube Feeding Administration Of, Ordering Of, Delivery Of" when staff failed to check for residual (fluid that remains in the stomach at a point in time during tube feedings) every four hours and to provide aspiration (accidental sucking in of food or fluids into the lungs) precautions/prevention for two out of two current pateints and one out of one discharged ptients reviewed for continuous tube feedings. Refer to A-0395 for additional information.

These deficient practices resulted in the facility's non-compliance with specific requirements found under 42 CFR 482.23 the Condition of Participation: Nursing Services.

Refer to the 2567 for additional information.

Based on observation, interview, and record review, the facility failed to ensure nursing staff consistently and accurately assessed, supervised and evaluated nursing care for wounds and/or pressure sores/ulcers (injury to the skin and/or underlying tissue usually over a bony prominence) for one discharged patient (#39) of one discharged patient reviewed, and five current patients (#19, # 40, #42, #43 and #27) of five current patients reviewed. The facility also failed to ensure ongoing nursing assessment, interventions, and oversight to meet the patient's care/services and/or prevention of complications on continuous tube feedings, for one discharged patient (#39) of one discharged patient reviewed, and two current patients (#17, and #26) of two current patients reviewed with continuous tube feedings. These failures had the potential to affect all patients admitted to the facility. The facility census was 209.


Findings Included:

Record review of the facility's policy titled, "Skin or Wound Assessment," dated 08/07/15, showed the directive for staff to:
- Perform initial skin assessment during the admission process;
- Initiate a care plan for patients who are identified to be at risk for skin breakdown and as indicated for wounds and skin conditions during the admission skin assessment or upon reassessment;
- Document skin or wound assessment with dressing changes; and complete weekly wound assessment including photographing and measuring wounds length, width, and depth;
- Consult Wound Care Nurse and wound staging is completed by Wound Care nurses and Physical Therapist only; and
- Document wounds on discharge.

Review of Patient #39's History and Physical (H&P) dated 12/22/17, showed the patient was not responsive (indicated the patient was not able to move on his own) and his skin was pink, warm, and dry.

Review of nursing admission assessment dated 12/22/17, showed the patient's skin was intact (without wounds), warm, dry, pink, and with no apparent friction (damage to the skin caused by a patient's back and forth movement of a surface) or problem. The Braden Score (an assessment tool for predicting the risk for a pressure sore, also known as a pressure ulcer) was 20 (scale is from six to 23, the lower the score, the higher the risk of developing a pressure ulcer).

Review of nursing assessments showed the patient's Braden Score declined from 20 on 12/22/17 to 10 on 01/02/18, and a nursing assessment dated 12/28/17 at 1:10 AM, documented that there was redness on the patient's buttocks (indicates raw skin or significant pressure to the area, such as when patients are not repositioned frequently, and increases the risk of skin breakdown).

During an interview on 04/04/18 at 10:20 AM, Staff QQ, Vice President of Operations stated that the Braden Tool score did not trigger wound consults.

Review of Patient #39's rounds assessment showed no consistent documentation of position changes (standard of care provided every two hours, to prevent pressure ulcers) during the evening and night hours from 12/23/17 to 01/04/18.

Review of an undated wound photograph, provided by the facility of Patient #39's coccyx (part of the buttocks) wound, showed an open wound.

During an interview on 04/04/18 at 1:27 PM, Staff WW, Registered Nurse (RN), stated that:
- There were no wounds documented on Patient #39's admission.
- A nursing assessment note from 12/29/17, showed a skin friction and shear (injury caused by dragging a patient's skin on a sheet) problem (location was not defined).
- She took a photograph of the patient's coccyx on 01/03/18, because he had an opened wound on his coccyx.
- She documented the wound's measurements in the medical record, and consulted the Wound Care Nurse (this was the first consult made to wound care, even though the patient showed a significant decrease in his Braden Score, redness and friction to his buttocks, and increased skin concerns).

Review of a nursing assessment dated 01/03/18 at 12:43 PM, documented by Staff WW, showed a buttock pressure ulcer, with red and irritated skin, which surrounded an open wound.

Review of an incision/wound care form dated 01/03/18 at 5:25 PM, documented by Staff WW, showed Patient #39's buttock pressure ulcer length was eight centimeters (cm, unit of measure) by seven cm in width.

Patient #39 showed a continued decline in his Braden score, which increased his risk for pressure ulcers. The patient developed signs of a possible impending pressure ulcer when redness was found on the patient's buttocks, and friction and shear problems were documented. The facility failed to document preventative interventions, such as frequent repositioning of the patient, or a consult to the wound care nurse, to prevent the patient from developing an open coccyx wound.

Review of Patient #42's Electronic Medical Health Record (EMHR) showed he was admitted to the facility on 03/30/18 at 5:29 AM with complaints of non-healing ulcers (a wound that does not improve after several weeks of care and treatment).

Review of the patient's History and Physical (H&P) dated 03/30/18 showed that the patient was admitted for an aortobifemoral bypass (surgery used to bypass diseased, narrowed or blocked blood vessels and then blood is redirected though a graft) for pain in his legs and non-healing ulcers.

Review of the patient's Admission Assessment History Adult Form showed:
- On 03/30/18 at 1:28 PM, staff documented under the Problems Active section of the assessment that the patient had ulcer of calf.
- On 03/30/18 at 1:53 PM, staff documented that the patient's current home treatments included wound care.
- On 03/30/18 at 2:44 PM, staff documented under the Integumentary (Skin) section of the assessment, the patient did not have a non-surgical wound and did not require a wound consult by the wound care nurse.

Review of the patient's Assessment Form under the Integumentary Section showed that on 04/02/18 at 11:52 PM, 04/03/18 T 9:00 AM and 8:40 PM, staff documented that the patient did not have a non-surgical wound and did not require a wound consult by the wound nurse.

Review of the patient's Critical Care Ongoing Assessment Form showed staff documented from 04/02/18 at 4:58 PM to 04/04/18 at 5:09 AM that the patient's Integumentary Document Assessment ICU: Assessment unchanged.

Review of the patient's Medication Administration Record (MAR) showed no orders that addressed care and/or treatment for the non-healing ulcers to his bilateral lower extremities.

Review of the patient's Plan of Care dated 04/03/18 at 6:56 AM, showed staff initiated heel protector boot orders.

Staff did not order heel protector boots for the patient until 24 hours after he had been admitted to the facility.

Observation on 04/04/18 at 8:23 AM showed the patient rested in bed on his back. The patient did not have heel protector boots on. The patient's left ankle had approximately a dime sized opened area that had a dark center with white tissue around the darkened area and red/pink tissue that surrounded the white tissue. The patient's right ankle had approximately a nickel sized opened area that had a small yellow center with white tissue around the yellow center and red tissue that surrounded the white tissue.

During an interview on 04/04/18 at 8:23 AM, Staff EEE, Registered Nurse (RN) Intensive Care Unit (ICU) Director, stated that the patient's EMHR did not contain documentation of the patient's non-healing ulcers that included a description of the ulcers, measurements (length, width and depth), location or photo on his Admission Assessment History Adult Form. Staff EEE stated that she did not know what the facility's standard and/or policy directed staff to do for patient's admitted with wounds/pressure ulcers.

During an interview on 04/04/18 at 1:04 PM, Staff QQ, RN, Vice President (VP) of Clinical Services, stated that the patient did not have any physician orders for wound care for his stasis ulcers (wounds on legs and/or ankles caused by decreased circulation) on both ankles and there was no order for a wound consult for the wound nurse.

Staff did not document the patient's non-healing ulcers to his bilateral (affecting both sides) lower extremities that included a description of the ulcers, location, measurements and condition of surrounding tissue on the Admission Assessment History Adult Form, on Assessments, or the Critical Care Ongoing Assessment Form. Staff also failed to take initial photos upon admission.

Review of Patient #20's medical record showed:
- H&P dated 03/30/18 showed the patient was admitted with a left decubitus (pressure) ulcer Stage IV (full thickness tissue loss with exposed bone, tendon or muscle and may have undermining and/or tunneling) of the left ischial (hip joint) region without erythema (redness) or purulent (pus) drainage with exposed muscle/fascia (a thin fibrous tissue that encloses muscle or an organ) and a Stage IV right hip ulcer with a clean base without erythema or purulent drainage.
- Physician orders dated 03/30/18 showed the following directives for staff:
- Photograph wounds upon admission, when found and prn (as needed).
- Measure wounds upon admission, when found and prn.
- Clean wounds with normal saline, pat dry, cover shallow wounds with Aquacel Ag (dressing used for the management of wounds by acting as a barrier to bacteria to help reduce infection), cover with abd (abdominal) pad (sterile moisture resistant barrier which provides padding and protection for large wounds), and do NOT tape.
- Pack deeper ulcers with Aquacel Ag, cover with abd pads, and do NOT tape.
- The patient's Admission Assessment Adult Form dated 03/30/18 showed staff did not document a description of his wounds that included measurements, location or condition of surrounding tissue under the Integumentary section of the assessment.
- The patient's Critical Care Initial Assessment Form dated 03/30/18 and 03/31/18 showed staff did not document a description of his wounds that included measurements, location or condition of surrounding tissue under the Integumentary section of the assessment.
- The Critical Care Ongoing Assessment Form from 03/30/18 at 4:18 PM to 04/01/18 at 1:38 PM showed staff documented on the Integumentary Document Assessment ICU: Assessment unchanged.

Staff did not document a description of his wounds that included measurements, location or condition of surrounding tissue.

Review of the patient's Incision/Wound Care Form showed that on 04/01/18 at 6:00 PM, staff documented the wound physician has been consulted, treatment plan initiated.

Wound Care Staff did not document a description of his wounds that included measurements, location or condition of surrounding tissue.

Review of the patient's Assessment System Focus Form dated 04/01/18 showed staff did not document a description of his wounds that included measurements, location or condition of surrounding tissue under the Integumentary section.

Review of the patient's Ongoing Assessment Form from 04/01/18 at 10:06 PM to 04/03/18 at 11:51 PM showed staff did not document a description of his wounds that included measurements or condition of surrounding tissue under the Integumentary section.

During an interview on 04/03/18 at 2:09 PM, Staff BB, RN, General Surgery Director, stated that she could not find documentation on the Admission Assessment Adult Form of the patient's wounds/pressure ulcers that included measurements, location or condition of surrounding tissue. Staff BB stated that she could not find any documentation in the patient's EMHR where staff documented a description of the patient's wounds/pressure ulcers that included measurements, location or condition of surrounding tissue.

Observation on 04/03/18 at 3:45 PM showed Staff DD, RN, entered the patient's room to perform dressing changes to his various wounds. Staff DD applied a new abd pad to the wounds/pressure ulcers and applied tape to the dressing and patient's skin.

Staff DD did not follow Orders when she applied tape onto the patient's skin.

Staff did not follow Orders when they failed to measure and document the patient's wounds/pressure ulcers upon admission/prn and applied tape to the patient's skin during wound dressing change.

Review of Patient #19's EMHR showed he was admitted to the facility on 03/25/18 with complaints of decubitus ulcers.

Review of the patient's medical record showed:
- The H&P dated 03/25/18 showed he was admitted to the facility with pressure ulcers to his sacrum (a large, flat triangular-shaped bone between the hip bones), left stump (below the knee amputation), right heel and left elbow.
- The Admission Assessment Adult Form dated 03/25/18 showed staff did not document a description of his wounds/pressure ulcers that included measurements under the Integumentary section of the assessment.
- The Critical Care Initial Assessment Form from 03/25/18 at 12:03 PM to 04/03/18 at 8:00 PM showed staff did not document a description of his wounds that included measurements under the Integumentary section of the assessment.
- The Incision/Wound Care Form from 03/26/18 at 1:41 PM to 04/03/18 at 1:37 PM showed staff did not document a description of 2 wounds that included measurements under the Integumentary section of the assessment.
- The Incision/Wound Care Form dated 04/04/18 at 1:02 PM showed staff documented measurements of the patient's various wounds/pressure ulcers 10 days after he had been admitted on 03/25/18.

Staff did not document measurement of the patient's various wounds/pressure ulcers when he was admitted on 03/25/18 and there was no documentation of measurements until 10 days after he had been admitted to the facility.

Observation on 04/04/18 at 9:18 AM showed Staff SS, RN, entered the patient's room to perform dressing changes. Staff SS removed old dressings from the various wounds, cleansed the areas, took photographs but did not measure each wound.

During an interview on 04/04/18 at 11:20 AM, Staff BB, RN, General Surgery Director, stated that she expected staff to do actual measurements of wounds/pressure ulcers and then document results into the patient's EMHR. Staff BB stated that her expectation was not for staff to take measurements from the photo(s) taken but to actively measure each wounds/pressure ulcers length, width and depth and then document the results.

During an interview on 04/04/18 at 11:40 AM, Staff SS, RN, stated that:
- She takes photos of patients' wounds/pressure ulcers and later takes the measurements from the photos and documents the results into the EMHR.
- When a patient is admitted to the facility, staff are expected to conduct a head-to-toe assessment.
- When a patient is admitted with wounds/pressure ulcers, staff are expected to take a photo of the areas, document measurements, location and condition of surrounding tissue on the Admission Assessment Adult Form.
- After the admission assessment, staff are to document skin assessments in the regular on-going assessment section under the Integumentary section of the form.
- Wednesday is considered "Wound Wednesday" and staff are expected to take photos of wounds/pressure ulcers and document a description of the wound to include measurements, location and condition of surrounding tissue.
- She consults the wound nurse for any opened areas on a patient.
- It is left up to the nurse and their judgement when a wound consult is requested for the wound nurse to assess a patient's skin/wounds/pressure ulcers.
- The facility did not have criteria for staff to follow when a wound consult should be requested and the decision to request a wound consult was left up to the nurse taking care of the patient.

During an interview on 04/05/18 at 9:55 AM, Staff DDD, RN, Wound Care Nurse, stated that:
- She was a certified wound nurse.
- When a wound consult is requested by staff, she looked at the entire patient's skin.
- She measured wounds/pressure ulcers if they are opened.
- She documented her assessment on the Incision/Wound Care Form.
- She documented any wound care that she provided.
- She initiated the care plan for skin integrity and pull over the problem per electronic if the patient has skin issues/wounds/pressure ulcers.
- Staff request a wound consult anytime they have concerns about patients' skin.
- She was responsible for staging wounds on patients she has been requested to assess.
- She does not follow up with patients after she has assessed the patient, however; she would see the patient again if staff requested for another consult.
- She does not automatically follow-up with a patient after she has made her assessment.
- She does not know if the facility has criteria for staff to follow when a wound consult should be requested.

During an interview on 04/05/18 at 10:00 AM, Staff QQ, RN, VP Clinical Services, stated that the facility did not have criteria for staff to follow as a guide for when a wound consult should be requested for a patient. Staff QQ stated that staff should put into place preventive pressure relieving measures when a patient's Braden Skin Scale changes and the patient is assessed at increased risk for skin issues/breakdown.

Staff failed to consistently take photos of patients' wounds/pressure ulcers upon admission, every Wednesday and prn. Staff also failed to consistently document description of patients' wounds/pressure ulcers that included measurements, location and condition of surrounding tissue upon admission, every Wednesday and prn. These failed practices by staff increased the potential for patients wounds/pressure ulcers to increase in size with increased tissue damage to surrounding tissue. Since staff did not consistently take photos, document description of the wounds/pressure ulcers they could not monitor if the areas were responding to care/treatment and if care/treatment needed to be changed.

Record review of Patient #40's medical record showed:
-The History and Physical (H & P) showed that the patient was admitted on 04/01/18 with three ulcers (an open sore that develops when skin is broken) on left foot.
-The admitting physician's assessment showed on 04/01/18 showed that the left lower extremity ulcers were "aggressive looking and he would consult podiatry."
-On the nursing assessment dated on 04/01/18 it showed the nursing staff took pictures of the ulcers at the time of admission and documented that the patient had three open ulcers on his left foot, but failed to document measurements of the ulcers.
-The wound care team consultation dated 04/02/18 documented that the wound care physician would follow the patient, but failed to document an assessment and measurements of the ulcers.
-The wound care physician's progress note dated on 04/03/18 documented that the patient was being taken care of by the podiatry team and he would defer to their treatment plan and be available if there was a second opinion required or if any new ulcers were identified.
-The podiatry consult dated 04/02/18 showed that the patient had three full thickness (damage extends below all layers of the skin) wounds over the middle, inner and outside of the left foot and that the patient told him he had crutches, cam walker (an orthopedic device that looks like a boot) and surgical shoes at home. He also documented that the wounds were "unwrapped and exposed to sock, no crutches, cam walker, or surgical shoe in sight" during his consult.
-The podiatry plan dated 04/02/18 was for the patient to elevate foot at all times when in bed, offload (to distribute the weight and relieve pressure) the left foot with crutch assist, cam walker, or surgical shoe, and partial pressure to the left foot. His treatment plan included orders for a sterile enzymatic debriding ointment and dry dressing to the ulcers. The documentation also noted that he had stressed the importance of the left foot wound care, risk of infection and loss of limb.
-The podiatry progress note dated 04/03/18 documented that the patient was evaluated sitting up in his chair with his left foot in dependent (dangling down) position without a boot/shoe in place.

During an interview on 04/04/18 at 1:30 PM, Staff TT, Registered Nurse (RN) Associate Director (AD) of the Rapid Observation Care Unit (ROCU) stated that he expected documentation, measurements, and photographs on the admission assessment, on the weekly wound assessment, and on the discharge assessment.

During an interview on 04/04/18 at 1:45 PM, Staff UU, RN stated that:
-All wounds should be measured, pictures taken, and documented on the admission assessment, weekly wound assessments, and on discharge.
-All interventions should be followed as ordered.
-If there were no current orders on admission the wound should be covered to prevent infection until the doctor and/or wound care team were notified

Observation on 04/03/18 at 1:44 PM, on Mental Health two south, showed Patient #27 lying flat in bed with right below knee amputation (BKA, surgical removal of limb) and a wound dressing on his left foot. The patient's left foot was lying flat on the bed without uploading (to raise a limb to prevent pressure of a wound.)

Review of Patient #27's medical record showed:
-H&P dated 03/24/18, showed that he was a 64 year old male that presented to the facility for mental health evaluation. He had been hallucinating (experiencing real perception of something not actually present.) He had a history of right BKA and a left heel ulcer. He had been non-compliant with treatment of left heel ulcer. The patient had an appointed guardian (guardian appointed to make decision for people who cannot make decisions for themselves.)
-The wound consultation note, dated 03/23/18, showed that the patient had a full thickness wound with exposed fat to the left posterior heel.
-The impaired tissue integrity plan of care, initiated 03/23/18, showed interventions to pillow float heels and pillow brace the patient at least 30 degrees of the trochanter (hip bone.)

During an interview on 04/03/18 at 1:55 PM, Staff HH, RN, stated that Patient #27 should have his left heel floated. The patient had been non-compliant with treatment.

Observation on 04/03/18 at 1:44 PM, on Mental Health two south, showed Patient #27 lying flat in bed with right below knee amputation (BKA, surgical removal of limb) and a wound dressing on his left foot. The patient's left foot was lying flat on the bed without uploading (to raise a limb to prevent pressure of a wound.)

During an interview on 04/04/18 at 9:20 AM, Patient #27 stated that he did not want his left foot elevated on a pillow because "if they elevate my foot I will bleed to death."

During an interview on 04/04/18 at 9:30 AM, Staff HH, Wound Care Manager, stated that:
- The wound care nurse was not consulted on Patient #27 because this group of physicians takes care of their own wounds;
- There were no orders directing the staff on preventive measures; and
- With the patient's mental status, the nurses should have offered an alternative intervention to prevent pressure on the patient's pressure ulcer, such as a heel protector boot.

During a telephone interview on 04/04/18 at 10:30 AM, Staff BBB, Physician, stated that patients with pressure ulcers on their heels should have interventions to prevent pressure on the wound.

Review of the facility's standards (policy) titled, "Tube Feeding: Administration Of, Ordering Of, Delivering Of," revised 05/26/16, showed the directives for tube feeding delivery, administration, care, and monitoring guidelines, which included to aspirate gastric content and document volume and color every four hours.

Review of Patient #39's Dietician order dated 01/02/18 at 12:50 PM, showed that the tube feeding (nutrition provided in liquid form, through a feeding tube) was to run at 30 milliliters (ml, unit of measure) per hour with 150 ml water flush, increase as tolerated by 10 ml every six hours until goal rate of 60 ml per hour, and water flush of 150 ml six times per day.

Review of the tube feeding assessments for Patient #39, showed that tube feeding residuals (amount of liquid nutrition left in the stomach, that has not been digested) were not documented on 01/04/18 from 00:57 AM to 7:47 AM, from 7:48 AM to 9:56 PM and on 01/05/18 from 9:56 PM to 10:06 AM.

Review of Patient #17's H&P dated 03/24/18, showed that he was a 64 year old male that presented to the facility very dehydrated and bleeding from tracheotomy stoma. He had a history of head and neck cancer. The plan was to re-hydrate with fluid supplement.

Review of Patient #17's physician's orders dated 04/02/18 at 12:18 PM showed tube feeding to begin at 60 milliliter per hour, increase by five milliliters per hour every eight hours as tolerated until goal rate of 75 milliliters per hour, and run 20 hours per day.

Observation on 04/03/18 at 10:05 AM, on Oncology two south, showed Patient #17 with a tracheotomy stoma (hole in throat that serves independently as an airway,) with a continuous tube feeding through a peg tube.

During an interview on 04/03/18 at 10:35 AM, Staff Z, RN, stated that:
- The nursing staff should aspirate gastric content from the peg tube and document volume every four hours in the tube feeding assessment portion of the EMHR;
- After review of the nurse's tube feeding assessments, she did not see any documentation where the staff had aspirated gastric content; and
- She had taken care of Patient #17 for two days and had not documented any aspirated gastric content.

Review of Patient #17's tube feeding assessment from 03/25/18 through 04/03/18 showed no evidence that the staff had performed or documented volume and color of any aspirated gastric content every four hours.

Observation on 04/03/18 at 10:45 AM, on Oncology two south, showed Patient #26 with a continuous tube feeding supplies in the room.

Review of Patient #26's H&P dated 03/24/18, showed that he was a 55 year old male that presented to the facility nausea and vomiting. He had a history of pancreatic, liver, and lung cancer. He was unable to tolerate food by mouth, Peg tube was placed in the stomach with a plan to provide supplement at night.

During an interview on 04/03/18 at 10:50 AM, Patient #26 stated that he had been eating a little through his mouth, and at night they start the tube feedings to help him gain weight. The tube feeding at night made his stomach feel "tight and full."

Review of Patient #26's physician's orders dated 03/29/18 at 1:33 PM, showed the tube feeding to begin at 80 milliliter per hour, run overnight for 14 hours from 6:00 PM through 8:00 AM.

During an interview on 04/03/18 at 10:55 AM, Staff AA, RN, stated with a patient that had a tube feeding the nursing staff were to aspirate gastric content and document every four hours the volume and color in the tube feeding assessment. After review of the tube feeding assessment, he did not see any documentation of aspirated gastric content.

Review of Patient #26's tube feeding assessment from 03/29/18 through 04/03/18 showed no evidence that the staff had performed or documented volume and color of any aspirated gastric content every four hours.

During an interview on 04/03/18 at 11:05 AM, Staff X, Oncology Associate Director, stated that it was the facility's policy for nursing staff on patients that were receiving tube feeding to aspirate gastric content and document volume and color every four hours. After she reviewed Patient #17 and #26's tube feeding assessments she did not see where staff had documented aspirated gastric content every four hours.

During an interview on 04/03/18 at 1:40 PM, Staff GG, Dietitian, stated that patients with tube feedings, it was vital that the staff aspirated gastric content to determine how much tube feeding was in the stomach and whether the patient was able to tolerate the tube feeding. Aspirating gastric content determined if it was safe to increase the tube feeding to goal rate.

During an interview on 04/03/18 at approximately 2:30 PM, Staff D, Chief Nursing Executive, stated that nurses should adhere to the facility's standards and follow the basic nursing standards.






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Based on observation, interview, record review and policy (standard) review, the facility failed to ensure staff followed their "Interdisciplinary Care Plan Standard" when staff failed to develop individualized comprehensive care plans for patients that included measurable objectives and timetables for:
- One (#42) out of one current patient reviewed with new onset of seizures and one (#39) out of one discharged patient reviewed.
- One (#4) out of one current patient reviewed that was placed in contact isolation.
- One (#26) out of one current patient reviewed with tube feedings (nutrition received via a tube inserted into the body) that included aspiration (accidental sucking in of food or fluids into the lungs) prevention/precautions.
These failures had the potential to affect all patients admitted to the facility as care was not planned. The facility census was 209.

Findings included:

Review of the facility's standard titled, "Interdisciplinary Care Planning Standard," reviewed 10/30/17, showed the following directives for staff:
- Care Plans are initiated and individualized based on the initial assessment upon admission and are reviewed and/or revised based on patient reassessment.
- Initiate and document plan of care for patient needs.
- Identify and develop goals to achieve optimal outcome.
- Revise care plan and goals as indicated.

Review of Patient #42's Electronic Medical Health Record (EMHR) showed he was admitted to the facility on 03/31/18 with complaints of altered mental status.
-The patient's History and Physical (H&P) dated 03/31/18 showed the physician documented that while the patient was in the emergency department (ED) the patient developed a grand mal seizure (causes a loss of consciousness and violent muscle contractions) and required intubation (insertion of a tube through the mouth and then passed into the airway to assist with breathing) for airway protection. Patient is to be admitted to the intensive care unit (ICU - special area of a hospital that provides intensive medical treatment.
-The physician orders dated 03/31/18 showed that there was no order for the new onset of seizures that included seizure precautions.
-The Plan of Care dated 03/31/18 showed staff did not include the patient's new onset of seizures that included seizure precautions with measurable objective and timetables.

During an interview on 04/03/18 at 9:09 AM, Staff EEE, Registered Nurse (RN), ICU Director, stated that the patient's care plan did not include his new onset of seizures and staff should have initiated a care plan for seizures.

Review of Patient #39's medical record showed:
-The H&P dated 12/22/17, showed that he was a 47 year old male with cognitive impairment and a history of mental retardation. He was admitted for new onset of seizures.
-There was no care plan for seizure precautions.
The patient's output record (measurement of liquid or solids that leave the body) showed no bowel movement recorded from 12/22/17 to 12/25/17. An order dated 12/26/17 for impaction (dry, retained bowel movement) check/remove (manually retrieve impacted bowel movement by inserting a finger into the rectum) and soap suds enemas (removal of bowel movements by putting a liquid substance or medication into the bowels through the rectum) until clear (no more stool). Abdominal x-ray dated 12/26/17 showed constipation. No care plan for altered bowel function was initiated.
-The physician order showed a tube feeding (liquid nutrition provided through a flexible tube, inserted into the patient's stomach) was initiated on 01/02/18.
-There was no care plan for aspiration (vomiting followed by breathing the vomit into the lungs) initiated (patients with tube feeding are at high risk for aspiration).

Review of Patient #4's H&P dated 03/26/18, showed that he was a 78 year old male that presented to the facility post-operative wound drainage. Wound culture was performed and showed Methicillin-resistant Staphylococcus Aureus (MRSA, an infection resistant to some antibiotics.)

Observation on 04/02/18 at 3:20 PM, on Orthopedic two east, showed Patient #4 in a contact isolation room.

Review of the patient's active care plans revealed no evidence the staff identified the patient's contact isolation problems.

During an interview on 04/03/18 at 10:55 AM, Staff E, RN, stated that staff should have generated a care plan to address Patient #4's contact isolation precautions.

Review of Patient #26's H&P dated 03/24/18, showed that he was a 55 year old male that presented to the facility nausea and vomiting. He had a history of pancreatic, liver and lung cancer. He was unable to tolerate food by mouth, Peg tube was placed in the stomach with a plan to provide supplement at night.

During an interview on 04/03/18 at 10:50 AM, Patient #26 stated that he had been eating a little through his mouth, and at night they start the tube feedings to help him gain weight. The tube feeding at night made his stomach feel "tight and full."

Review of the patient's active care plans revealed no evidence the staff identified the patient's problem for risk of aspiration associated with nocturnal tube feedings.

During an interview on 04/03/18 at 11:05 AM, Staff X, Oncology Associate Director, stated that Patient #26 did not have risk for aspiration care plan. Patients that have received tube feedings should have a care plan addressing the risk for aspiration.

During an interview on 04/03/18 at approximately 2:30 PM, Staff D, Chief Nursing Executive, stated that nurses should develop a care plan and follow the basic nursing standards.


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