HospitalInspections.org

Based on findings from document review, medical record (MR) review and interview, in 3 of 9 MRs reviewed for patients at risk for pressure ulcer development (Patient #'s 1, 2 and 3), nursing care, as documented, in connection with skin care did not meet generally accepted standards of nursing practice. Specifically, Braden Scale scores were not documented every shift, heel elevation was not documented consistently and position patient was placed in (repositioning) was not documented consistently. This could lead to skin breakdown.

Findings include:

-- Review of the hospital policy and procedure (P&P) titled "Skin Care Policy and Procedure," last revised 1/2017, indicated that nursing staff should perform a pressure ulcer/injury risk assessment upon admission and every shift thereafter using the Braden Scale and implement the appropriate treatment plan based on the Braden Score and skin/wound assessment. Braden Scale scores indicate risk level for pressure ulcer development, mild risk 15-18, moderate risk 13-14, high risk 10-12, very high risk 9 or below. The score is determined by the total of subscores for categories of sensory perception (able to respond meaningfully to pressure related discomfort), moisture (degree to which skin is exposed to moisture), activity (degree of physical activity), mobility (ability to change and control body position), nutrition (usual food intake pattern), and friction and shear. Interventions should be implemented for subscore of 1, 2, or 3 for the following Braden risk factors identified with sensory perception, activity and mobility or a score of 1 or 2 for friction and shear. Interventions include: pressure redistribution support surface, chair cushion, heel protectors, elevate heels off bed with pillows lengthwise, heel floats if signs or evidence of pressure, reposition every 2 hours and document (staff should document a patients position/repositioning on the positioning flowsheet or designated area for the documentation including heels off bed), etc.

-- Per review of Patient #1's MR, he was admitted on 9/16/16 with questionable ST elevation myocardial infarction, respiratory failure and aspiration pneumonia. Past medical history included cerebral vascular accident, peripheral vascular disease, carotid artery stenosis, atrial fibrillation, deep vein thrombosis, ischemic cardiomyopathy. and hypertension. On admission (6:30 pm) Patient #1's Braden scale score was 15. Specific sub scores were: Activity-3 (walks occasionally), Mobility-2 (very limited) and Friction and Shear-2 (potential problem). There was no documentation regarding heel elevation until 7:00 am on 9/17/16 (over 12 hours later).

On 9/17/16 at 7:00 pm Patient #1's Braden score was 14 moderate risk, subscores were Activity-3, Mobility-2 and Friction and Shear-2. There was no documentation indicating heels were elevated from 9/17/16 at 7:00 am until 9/18/16 at 9:20 am (26 hours).

On 9/18/16 at 7:00 am, Patient #1's Braden score was 12 - high risk, subscores were Activity-1 (bedfast), Mobility-2 and Friction and Shear-2. Skin was intact, no areas of breakdown were noted. There was no documentation of another Braden scale score until 9/19/16 at 7:00 am (24 hours from previous assessment) and documentation of heel elevation was noted only once from 9/18/16 at 7:00 am until 9/19/16 at 7:00 am (24 hours later).

On 9/19/16 at 6:45 am, physician documentation indicated, Patient #1's speech was garbled and seemed confused, left side flaccid. Nursing documentation at 7:00 am indicated skin remains intact, no areas of breakdown noted. Braden score 11-high risk, subscores were Activity-1, Mobility-2 and Friction and Shear-2. Nursing documentation from 7:00 am - 7:00 pm, indicated Patient #1 was repositioned with assist every 2 hours, however, there was no documentation regarding the position the patient was in or that heels were elevated during that time. There was no documentation of another Braden score until 9/20/16 at 7:00 am (24 hours from previous assessment).

On 9/20/16 at 7:00 am, nursing documented an acute change in mental status from baseline. Skin intact, Braden score 12. Nursing documentation from 5:00 am - 7:00 pm, indicated Patient #1 was repositioned with assist every 2 hours, however, there was no documentation regarding the position the patient was in during that time or that his heels were elevated. At 9:00 am, nursing documented pressure ulcer/injury location right heel, deep tissue injury. Referral sent to the certified wound ostomy nurse (CWON).

-- The same lack of documentation of Braden scale score being performed every shift was found in Patient #2's MR for time frame of 8/4/17 - 8/8/17 and the same lack of consistent documentation of heel elevation and position documentation was found in Patient # 3's MR for time frame of 7/20/17 - 7/26/17.

-- During interview of Staff A (Clinical Educator) on 8/10/17 at 1:00 pm, the above findings were verified.

Based on findings from document review, medical record (MR) review and interview, in 1 of 1 MRs reviewed, a physician order for blood transfusion was not complete and hospital policy and procedure (P&P) on blood transfusions lacked generally accepted requirements that the rate/duration of the transfusion be specified in the physician's order.

Findings include:

-- The New York State Council on Human Blood and Transfusion Services and the New York State Board of Nursing "Guidelines for Monitoring Transfusion Recipients," last revised 2012, indicates after the transfusion is initiated the rate of flow should be observed and regulated according to the physician's orders.

-- Per review of Patient #4's MR, a physician order dated 8/9/17 at 8:00 am, stated to transfuse 2 units of PRBCs (packed red blood cells). No rate/duration for the transfusion was specified.

-- Per review of the hospital P&P titled "Blood and Blood Product Transfusion," last revised 3/2017, it indicated that the provider should order specific type of blood component and indication for it. Registered Nurses should infuse blood at rate of 80 milliliters per hour for first 15 minutes and then "adjust rate appropriately."

-- During interview of Staff B (Director of Regulatory Affairs) on 8/9/17 at 3:00 pm, he/she acknowledged the above findings.

Based on findings from medical record (MR) review and interview, in 1 of 10 MR reviewed, medical staff orders for pain medications to be administered on a PRN (as needed) basis did not provide instructions to nursing staff regarding when to administer which of the pain medications ordered. Also, in 1 of 10 MRs, two dosages of a single PRN medication were present on the medication administration record without indication of when each dose should be administered. This could lead to patients being over/under medicated.

Findings include:

-- Per review of Patient #4's MR, he was admitted to the hospital on 8/5/17 post cardiac arrest. On 8/6/17 at 12:30 pm, Staff C (Physician) ordered hydrocodone/acetaminophen 7.5/325 milligrams (mg) 1 tablet every 6 hours PRN for pain. On 8/7/17 at 12:29, Staff D (Physician) ordered Fentanyl 50 micrograms (mcg) every 2 hours intravenously PRN for pain. There were no parameters ordered to indicate when nursing staff should administer which medication.

-- Per review of Patient 3's MR, she was admitted to the hospital for cardiac surgery. On 7/31/17 at 7:44 pm, Staff E (Physician) ordered Haldol 5 mg intravenously every 6 hour PRN for agitation. On 8/4/17 at 2:30 pm, Staff F (Physicians Assistant) ordered Haldol 2 mg intravenously every 6 hours PRN for agitation. Both were active medications orders and there were no instructions to nursing staff indicating which dose should be administered to the patient.

-- During interview of Staff G (Assistant Director Pharmacy) on 8/10/17 at 1:30 pm, he/she acknowledged that the medication orders lacked a clear indication for when each of the 2 pain medications ordered should be administered. He/she also acknowledged that the medication order for Haldol 5 mg should have been discontinued when the order for 2 mg was written and was not sure of the reason that pharmacy staff had not done so.