HospitalInspections.org

Based on document review and interview, the nursing supervisor failed to ensure that nursing staff documented repositioning every 2 hours, for those patients scoring as a moderate or high risk for skin issues, for 3 of 10 patients, patients #5, #6 and #10 and nursing supervisor failed to ensure nursing staff followed policy & procedure for vital signs for 2 of 10 patients (patient #3 and #8).

Findings Include:
1. Review of the policy Skin Assessment and Prevention of Pressure Ulcers, no policy number, last approved on 4/13, indicated the Braden scoring tool is utilized to assess possible skin issues for patients.
A. On page 5, it reads that a score of 15 to 18 is Mild Risk and the patient is to have a "Care plan: Mild Risk for Pressure Ulcer 15 - 18" with the nursing staff to "Reposition minimally every 2 hours if unable to turn self."
B. On page 6, it reads that for scores of 13 - 14, a Moderate Risk, the patient is to be "...Repositioned minimally every 2 hours if unable to turn self...".
C. On page 7, it reads that for scores of 10 - 12, High Risk, the patient is to be "...Repositioned minimally every 2 hours if unable to turn self...".

2. Review of patient medical records indicated:
A. Pt. #5 scored 14 (Moderate Risk) on the Braden tool on admission 3/15/16. It was also noted on:
a. 3/15/16 at 2200 hours that the patient "turns self".
b. 3/16/16 at 0018 hours that the patient was "bedrest" and needed "mod assist".
c. 3/16/16 lacked documentation for repositioning from 0800 hours to 1252 hours and from 1400 hours to 2051 hours.
d. 3/17/16 from 0200 hours to 0710 hours lacked documentation of repositioning.

B. Pt. #6 scored 12 (High Risk) on admission (3/15/16) according to the Braden scoring tool and later scored 12, 11, 10 and 8. Other documentation included:
a. On the med/surg nursing unit on 3/15/16 from 1819 hours to 0047 on 3/16/16 lacked repositioning documentation or on 3/16/16 from 0047 to 0421 and 0421 hours to 0854 hours.
b. On 3/16/16, in the ICU (intensive care unit), there was no every two hours repositioning noted between 0854 hours and 1200 hours and from 1200 hours to 1500 hours.
c. On 3/17/16, lacked documentation of repositioning every two hours between 0600 hours and 0900 hours.

C. Pt. #10 was a 68 year old admitted on 4/11/16 with a Braden score initially of 15 (Mild Risk) with other assessments being 14 and 15.
a. On 4/12/16, lacked repositioning documentation between 0100 hours and 0600 hours; from 0900 hours to 1600 hours; and from 1600 hours to 2300 hours
b. Lacked repositioning documentation from 2300 on 4/12/16 to 0612 on 4/13/16, and lacked documentation made after 0612 hours to the time of record review at 1206 hours.

3. At 3:10 PM on 4/12/16 and 11:15 AM on 4/13/16, interview with staff members #50 and #55, quality and accreditation specialists, confirmed that documentation for patients #5, #6 and #10 lacked documentation every two hours, per policy and care plans, regarding repositioning, or that the patient was turning themselves.

4. Review of the policy Clinical Standards of Care Perioperative, no policy number, last approved on 6/2015, indicated on page 6: "Vital Signs" were to be taken at "Admit/every 5 min x5 (sic), then every 15 min...".

5. Review of the medical record for patient #3 indicated the patient arrived in the PACU (post anesthesia care unit) at 1149 hours on 1/22/16 and had VS taken at 1150 hours, 1155 hours and 1200 hours with no further VS noted until a code blue was initiated at 1214 hours.

6. Review of the document Critical Care Standards --Advanced Post- Operative ICU (intensive care unit) Patient Care Standards, no number or date of approval, indicated patients who recover in the critical or intensive care units are to have documentation for: "...Document warming device and temperature on Admission; Vitals on Admit then every 5 minutes x 5, then every 15 minutes x7 (sic), then hourly...".

7. Review of the medical record for patient #8 indicated they went to the critical/intensive care unit after surgery on 4/12/16 at 1815 hours and had VS taken every 15 minutes at 1815 hours, 1830 hours, 1845 hours, 1900 hours, 1915 hours, 1930 hours and 1945 hours.

8. At 11:30 AM on 4/13/16, interview with staff member #55, a quality and accreditation specialist, confirmed that the post op VS for patients #3 and #8 were not every 5 minutes x 5 as per facility policies and protocols.

Based on document review and interview, the facility failed to ensure the completeness of PACU (post anesthesia care unit) documentation in the medical record for 1 of 3 surgical patient records reviewed, Patient #3.

Findings Include:
1. Review of the document Critical Care Standards --Advanced Post- Operative ICU (intensive care unit) Patient Care Standards, no number or date of approval, indicated patients who recover in the critical or intensive care units are to have documentation for: "...Vitals on Admit then every 5 minutes x 5, then every 15 minutes x7 (sic), then hourly...".

2. Review of medical records indicated:
A. Patient #3 had surgery on 1/22/16, was taken to PACU at 1149 hours with the first VS (vital signs) taken at 1150 hours. At 1151 hours, the patient was documented as being on the ventilator. VS were taken at 1155 hours and 1200 hours. At 1205 hours no VS were charted and the oxygen level was at 91%; at 1210 hours, respirations were 13 and the oxygen saturation was 92%, but no VS were taken. The medical record noted that a Code Blue was called at 1214 hours with compressions initiated.
B. Patient #3 had a hospitalist note written at 1255 hours on 1/22/16, and "filed" at 1328 hours, that indicated: "Called for code blue. Patient sp (status post) lap cholecystectomy. Developed respiratory failure post extubation and then went into PEA (pulseless electrical activity). CPR (cardio pulmonary resuscitation) initiated. Patient was reintubated...".

3. Review of the document related to the code blue committee evaluation on 2/11/16 of patient #3's code indicated: "...Code Blue was initiated. More than thirty (30) people responded. The first endotracheal tube was placed and resuscitation efforts began. The Code went well ...The first tube was pulled and the second one placed and the ETCO2 (End-Tidal Carbon Dioxide) (winky) was used and confirmed the endotracheal tube was correctly positioned to ventilate the lungs. After the second intubation, the team got [the patient] back right away..."

4. At 11:50 AM on 4/12/16 interview with staff member P1, the pre op nurse for patient #3 on 1/22/16, confirmed that they remembered the patient was "fully awake when extubated" in the PACU, prior to the arrest.

5. At 10:05 AM on 4/13/16, interview with PACU nurse #59 confirmed that there was no other nursing notes or documentation in patient #3's medical record related to the patient's PACU time between 1210 hours (respirations and oxygen saturation level) and 1214 hours, that there was no documentation related to patient #3 being extubated in PACU, and that criteria had been met to complete the extubation process.

6. At 11:15 AM on 4/13/16 , interview with staff member #55, a quality and accreditation specialist, confirmed that:
A. There is no facility policy related to the completeness of medical records.
B. The medical record for patient #3 was incomplete for documentation related to extubation time prior to a re intubation during the code blue, as noted by the hospitalist who attended the code. It was also confirmed that there was no PACU documentation between 1210 hours and the code which began 1214 hours.
C. It was unclear what occurred in the PACU prior to the code of 1214 hours on 1/22/16.