HospitalInspections.org

Based on record review, policy review and staff interview, it was determined the facility failed to ensure that a registered nurse provided appropriate nursing care related to pressure ulcer prevention, prevention of fecal impaction, Foley catheter care and the provision of hygiene care for 4 (#1, #3,#4 #5) of 13 sampled patients. This practice does not ensure that patient care goals are met.

Findings include:



1. The facility's policy "Care of the Patient at Risk for Skin Breakdown/Pressure Ulcer", # 2000.001.7, revised 2/10 required that a patient with a Braden Activity/Mobility risk factor score of 2 or less is to be repositioned every 2 hours.

Patient #1 was admitted to the facility on 2/1/12. He remained in the facility until 3/12/12. Review of the history and physical revealed the diagnosis of metastatic carcinoma. The patient's chief complaint was severe back pain. Review of nursing documentation revealed that the patient was initially assessed to have a Braden score of 18. The mobility score was 3, or slightly impaired. On 2/6/12, the score decreased to 15 and the mobility score was 2. The Braden score decreased during the hospital stay and was 8 - 9 by 2/28/12. The mobility score was 1, indicating the patient was immobile. The skin assessment on 2/28/12 indicated the patient's coccyx was red. Review of the care plan section of the nursing documentation revealed that the patient was repositioned only 6 times on 2/29. On 2/29/12, the nurse documented a stage II blister on the coccyx. On 3/1/12, the patient was repositioned only 5 times. On 3/2, 3/3, 3/4 and 3/5, the patient was repositioned only 5 - 6 times each day. The patient was repositioned 7 times on 3/6 and 3/7, 9 times on 3/8, and 6 times on 3/9/12. On 3/10/12 the nurse documented the coccyx wound was unstagable and was covered with black eschar. There was no documentation of repositioning at all on 3/10/12. On 3/11/12 the patient was repositioned only at 3:30 p.m. and 8:00 p.m. There was no other documentation of repositioning for that day.

The patient was discharged to hospice on 3/12/12 at 4:30 p.m. There was no documentation of repositioning on 3/12/12 at any time. The Patient Safety Officer reviewed the record on 9/27/12 at approximately 4:00 p.m. and confirmed the above findings.

Patient #5 was admitted to the facility on 9/9/12 with the diagnoses of respiratory failure, end stage renal disease, and hypoglycemia. The care plan listed at risk for skin breakdown as a problem to be addressed. The Braden score was 9 with the mobility score of 1. Review of nursing documentation revealed the patient was repositioned only 4 times on 9/24, 3 times on 9/25, 1 time on 9/26 and 6 times on 9/27/12. The nursing manager was present during the record review on 9/28/12 at approximately 2:00 p.m. and confirmed the above findings.

The facility failed to reposition patient #1 at a minimum of 12 times (24/2 = 12) a day once his mobility risk factor was equal to or less than 2.


2. The facility policy "Indwelling Urinary Catheter: Insertion, Care, and Removal" #.00.050.2, effective 10/29/10 requires that Foley catheter care be provided twice daily. Review of nursing documentation for patient #1 revealed that the Foley was inserted on 2/3/12. Review of the " Patient Activity Treatment form revealed no documentation of Foley catheter care on 2/3, 2/4, 2/5, 2/7, 2/8, 2/9, 2/12 - 2/18, 2/20 - 2/29, and 3/2 - 3/12. The Patient Safety Officer confirmed the findings on 9/27/12 at approximately 4:00 p.m.

Review of the medical record of patient #3 revealed the patient was admitted to the facility on 9/22/12 with the diagnosis of abdominal pain and recurrent urinary tract infection. Review of nursing documentation revealed that a Foley was inserted on 9/22/12. Review of nursing documentation revealed that Foley catheter care was provided only once per day on 9/24 - 9/27. The nursing manager was present during the record review on 9/28/12 at approximately 10:30 a.m. and confirmed the findings.

Review of the medical record of patient #4 revealed that he was admitted on 9/21/12 with the diagnosis of metastatic pancreatic carcinoma. Review of nursing documentation revealed a Foley was inserted on 9/21/12 and removed on 9/24/12. Review of nursing documentation revealed Foley care was provided only once on 9/22 and 9/23. The nursing manager was presented during the record review on 9/28/12 at approximately 12:30 p.m. and confirmed the findings.

The facility failed to provide Foley catheter care two times a day as required by facility policy.

3. Review of nursing documentation regarding fecal elimination for patient #1 revealed that the patient failed to have a bowel movement from 2/1/12 until 2/15/12 and then not again until 3/7/12. The physician had ordered lactulose 30 cc twice daily as needed.

Review of the website www.drugs.com/pro/lactulose.html, page 2, revealed lactulose is used to treat constipation.

Review of the Medication Administration record revealed lactulose was administered once on 2/2, 2/8, 2/9, 2/12 and 2/13. The nurses documented that the patient had not had a bowel movement, but failed to provide the medication as ordered. The physician wrote an order for a fleet's enema, which was administered with good results on 2/15/12. The physician discontinued oral medications on 2/18/12 due to dysphasia. The nurses failed to document when the last bowel movement had occurred from 2/18 until 2/26. The nurses documented the last bowel movement had been on 2/15/12. No intervention was initiated until 3/7/12 when another fleet's enema was administered.

Review of the Patient Activity Care form for patient #1 revealed that patient bath was documented only on 2/1, 2/6, 2/6, 2/10, 2/11, 2/19 and 3/1.

The Patient Safety Officer confirmed these findings on 9/27/12 at approximately 4:00 p.m.