HospitalInspections.org

Based on document review and interview, the governing board failed to ensure that the medical staff followed the facility policy related to the completion of a psychiatric evaluation within 60 hours of admission for 1 of 5 closed medical records reviewed, Patient #10.

Findings Include:
1. The policy Timeliness of Medical Record Completion, policy number III - A.9, last approved/issued 5/2015 indicated the psychiatric evaluation was to be completed within 60 hours of admission.

2. Review of the medical record for patient #10 indicated the patient was admitted on 11/30/15 and the psychiatric evaluation was done and dictated on 12/11/15.

3. At 1:00 PM on 9/28/16 interview with staff member #52, the regional quality/risk staff member, confirmed that the psychiatric evaluation for patient #10 was not done until 12/11/15 which was not per facility policy and that it was unknown why there was such a delay in providing this service to the patient.

Based on document review and interview the nursing supervisor failed to ensure that nursing staff followed physician orders related to skin care and blood sugar monitoring for 4 of 11 patients, Patients #2, #3, #5 and #10 and failed to follow the facility policy related to weekly skin assessments for 2 of 5 open medical records, Patients #2 and #6.

Findings Include:
1. The policy Wound Care Assessment and Treatment, policy number II - D.1, last revised 8/2016 indicated:
A. Under Policy, it reads: "Wounds will be measured on admission, at occurrence, weekly, and at discharge if wound remains open...".
B. Under "Procedure for Wound Treatment", "1. A treatment order will be obtained upon identification of a pressure-related or non-pressure related wound. The order will include cleansing, the type and amount of topical product...2. The treatment order will be transcribed to the Medication Administration Record (MAR)...4. Treatment will be completed in accordance with the physician's order and will be documented on the MAR...".

2. The policy Pressure Ulcer Prevention/Pressure Ulcer Risk Assessment, policy number II - D.27, last revised 9/06/16 indicated under "Procedure", "All patients will be assessed for the risk of skin breakdown through the Braden Pressure Ulcer Risk Assessment upon admission during completion of the Nursing Admission Database...4. Licensed nurses will complete a head to toe skin assessment at least once per week for all patients during hospitalization to identify early visible signs of changes in skin integrity...".

3. Review of medical records indicated:
A. Patient #2:
a Had an order for Accuchecks to be done the evenings of Tuesday and Thursday with the MAR lacking documentation of an Accucheck being done the evenings of 9/20/16 (Tuesday) and 9/22/16 (Thursday).
b. Was admitted on 9/10/16 and had a head to toe assessment done, but lacked the weekly head to toe assessment that should have been done on 9/17/16.
B. Patient #3 had Bacitracin written on the MAR to be applied to the "Right Knee open area three times a day with foam dressing and knee pad" that was not documented on the MAR as being done at 9 AM and 2 PM on 8/10/16.
C. Patient #5 had Bacitracin written on the MAR to be applied to the right leg bid (two times/day) that lacked documentation on the MAR of administration of the 9 AM treatment on 8/22/16, 8/24/16 and 8/25/16 and lacked 9 PM documentation on 8/25/16.
D. Patient #6 was admitted on 9/18/16 and had a weekly head to toe assessment completed, but the weekly assessment did not address any of the issues noted on the admission assessment, including but not limited to, bruising.
E. Patient #10 had, per the MAR, barrier cream to be applied to the coccyx/perineal areas every shift with no documentation on the MAR for the AM and PM doses on 12/11/15 or the PM shift on 12/12/15.

4. At 9:40 AM on 9/28/16, interview with the wound nurse, staff member #56, confirmed that staff may be confused about how to do the weekly skin assessments and how to document any changes from those done on admission as this is still a new process for the nursing staff.

5. At 10:35 AM and 3:30 PM on 9/27/16 and 9:45 AM on 9/28/16, interview with the regional quality/risk staff member #52, confirmed that:
A. Documentation on the MAR for skin/wound topical application as listed in 3. above was lacking.
B. The weekly head to toe skin assessment for patient #6 was confusing and did not address issues found at the time of admission.

Based on document review and interview the facility failed to ensure the completeness of medical records for 4 of 11 records reviewed, Patients #5, #7, #9 and #11.

Findings Include:
1. Review of the policy Timeliness of Medical Record Completion, policy number III - A.9, last approved/issued 5/2015 indicated under "Procedure": "1. All medical record entries must be legible, complete, dated, timed and authenticated promptly...".

2. Review of medical records indicated:
A. Patient #5 lacked completion of the 15 minutes checks on the Patient Observation Monitoring Rounds form on 8/19/16 from 1215 hours to 1445 hours and from 1915 hours to 2000 hours.
B. Patient #7 lacked completion on:
a. The Nursing Admission Database form for the "Time Admitted" and the "Date".
b. The Nursing-Daily Assessment form for the night shift of 9/25/16 where the form was blank for 2/3 of the page.
c. The 15 minutes checks on the Patient Observation Monitoring Rounds form for 9/22/16 from 0715 hours to 0745 hours; 9/23/16 from 2245 hours to 2345 hours and on 9/27/16 from 0730 hours to 0830 hours.
C. Patient #9 lacked documentation on the Patient Observation Monitoring Rounds form for 9/27/16 from 0715 hours to 0830 hours.
D. Patient #11 lacked documentation on the Patient Observation Monitoring Rounds form for 12/17/15 from 2100 hours to 2345 hours; on 12/18/15 for 0730 hours and 0745 hours; for 12/24/15 from 0715 hours to 2345 hours and for 12/27/15 from 1115 hours to 1845 hours.

3. At 1:00 PM on 9/28/16, interview with the corporate quality/risk staff member #54, confirmed that document in the medical records was not complete as listed in 2. above.