HospitalInspections.org

This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure licensed nursing staff conducted an assessment for change of condition, failed to notify the physician for change in condition, failed to obtain a physician's order for the use of heat therapy, and failed to ensure unlicensed staff were not able to determine treatment modality, thus providing heat therapy without a physician's order. Such actions resulted in multiple hot water burns to patient's neck, shoulder, chest, breast, abdomen, and hip. This also caused patient #1 excruciating pain, physical trauma, transfer to a burn unit, separation from family members and extended hospitalization for 1 of 3 sampled patients (Patient #1). This resulted in Immediate Jeopardy which began on 9/20/2021.

Findings:

Cross Reference A 396.


An onsite revisit was conducted on 04/04/22 to demine if the findings of ongoing Immediate Jeopardy, originally identified during the survey ending on 10/20/21, could be removed. This revisit resulted in the determination that the seriousness was removed on 11/08/21.

Review of the immediate corrective measures implemented by the hospital revealed the following, which were verified on 04/04/22.
On 11/08/21 the hospital completed the following:
* A written policy for Heat/Cold Therapy was developed and approved on 10/18/21. The policy included types of heat application, physician order required, use of Aquathermia Pad (K Pad), patient assessment and reassessment, contraindications, special precautions for pediatric and elderly patients, general instructions, implementation of heat therapy and documentation.

* Nursing staff were educated on the Heat/Cold Therapy policy and process to follow if a patient requests heat therapy. Review of the signature forms revealed 100% of nursing staff had completed the education by 11/08/21.

* A notice to "Do Not Use Hot Water," from the coffee maker for heat application was placed on all coffee makers on all nursing units. A clipboard with staff roster was placed on the wall by all coffee makers for staff to sign acknowledging they had read and understand the notice. Review of the signature forms revealed 70% of nursing staff had completed by 10/08/21 and 100% of staff had completed by 10/18/21.

* Development of a High-Risk Packet was added to nursing agency staff and travel nurse orientation. NetLearning for agency staff and travel nurse included Policy Review for Clinical Partners for Heat Application with three quiz questions: 1. What are some contraindications for heat therapy? 2. How do you implement heat therapy? 3. What type of heat therapy can you use at Parrish Medical Center?

* Review of four new hospital employees (1 Registered Nurse, 1 Licensed Practical Nurse and 2 Certified Nursing Assistants) revealed acknowledgement of the Heat Therapy Policy.

* Review of two agency nurse orientation packets revealed signature on the Clinical Orientation Acknowledgement form and Computer-Based Learning System which included the Heat Therapy Policy with quiz completion.
An attestation was added to the Registered Nurse (RN), Licensed Practical Nurse (LPN), Nurse Technician (NT) and Certified Nursing Assistant (CNA) job descriptions. The attestation read, "By signing this job description, I attest that I shall function only within my scope of practice as defined by this job description and the Florida Board of Nursing Code and Nurse Practice Act found at: http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statutes&Sear_String=&URL=0400-0499/0464/0464PARTIContentsIndex.html

* Review of 1 RN, 1 LPN, 1 NT and 1 CNA job description revealed the attestation was included and signed by the employees.

* Review of the random on-going audits completed by the Director of Medical/Surgical included RN's, LPN's, NT's and CNA's. The audit included question, "A patient asks you for a heating pad or hot water bottle. How do you accommodate this request?" The audits revealed 100% compliance and continue to be on-going.

* Review of 3 patient's medical records revealed all 3 patients had a physician's order for heat therapy with use of Aquathermia Pad. Two of the three patients were assessed by the nurse prior to heat therapy application and the medical record contained documentation of the heat therapy use. One patient did not require the use of the heat therapy.

* Staff interviews conducted on 04/04/22 with 1 RN, 1 LPN and 1 NT revealed the hospital had provided education on Heat Therapy policy.

* Review of the Quality Assurance and Performance Improvement (QAPI) plan was conducted on 04/04/22 at 2 PM with the Chief Nursing Officer (CNO), Risk Manager (RM) and Executive Director of Quality. The CNO stated the hospital's interventions including development of the Heat Therapy Policy, Heat Therapy policy education for all nursing staff, addition of the Heat Therapy policy and attestation to the orientation process for all staff including agency and travel nurses, the Aquathermia Pads in the Pyxis System (Physician order to remove) and on-going random audit will ensure compliance. The hospital has not had any further issues with hot water burns.

Based on observation, interview, and record review, the facility failed to ensure licensed nursing staff conducted an assessment for change of condition, failed to notify the physician for change in condition, failed to obtain a physician's order for the use of heat therapy, and failed to ensure unlicensed staff were not able to determine treatment modality, thus providing heat therapy without a physician's order. Such actions resulted in multiple burns to the body, excruciating pain, physical trauma, transfer to a burn unit, separation from family members and extended hospitalization for 1 of 3 sampled patients (Patient #1). This resulted in Immediate Jeopardy which began on 9/20/2021.

Findings:

Patient #1's medical record reflected that the patient was admitted to the hospital on 9/13/21 with diagnoses of near syncope, nausea, vomiting, gastrointestinal (GI) bleed, and a history of cerebral vascular accident (CVA). Admission physician orders included physician consultations for GI, Cardiology, Neurology, and Discharge Planning to return home.

A nurse's note on 9/20/21 at 5:44 PM reflected that Registered Nurse (RN) A witnessed a bag of hot water, which had been placed on the patient's right shoulder, had opened, and burned the patient's right chest, breast, side and around to her back.

A physician's progress note on 9/21/21 revealed he was made aware of the 9/20/21 event which resulted in patient #1 being burned. The physician ordered Silvadene Ointment for the treatment of the burns and a Wound Care Consultation. On 9/27/21, the physician discussed patient #1's burn status with a physician at a local acute care hospital burn unit, and the decision was made to transfer patient #1 to the burn unit for assessment and treatment. Skin examination reflected patient #1 had burns to the right neck, shoulder, breast and hip and required wound care daily.

On 9/27/21, the physician ordered patient #1 to be transferred to a local acute care hospital burn unit.

The Wound Care Notes from 9/22-26/2021 reflected that patient #1 had first degree and second- degree partial thickness burns to the right shoulder, chest, breast and abdomen with erythema (redness) and blisters. On 9/27/2021, the right breast was inflamed, pink with second degree burns. Biofilm was scattered throughout and removed during the cleaning process but was very adherent. Treatments were provided by the wound nurse daily until transfer to the acute care hospital burn unit.

Patient #1's medical record reflected that patient #1 was transferred to a local acute care hospital burn unit on 9/29/21 and returned to this admitting hospital on 10/12/21.

The acute care hospital Progress Notes and History and Physical reflected that patient #1 stated she sustained burns from spilt hot water and had pain at her sternum with mild numbness and tingling. There was a full thickness burn to the right center of the chest, which was white, non-blanchable and minimal sensation. There was thick pseudo eschar around much of the chest wall that was not easily removed with a gloved finger. The surrounding area had partial thickness, and was blanchable, pink and moist. There was evidence of superficial thickness burns to the patient's right hip and right shoulder. Patient #1 was admitted to the burn stepdown unit. Xeroform and Bacitracin were applied to the burns, and a high calorie, high protein diet and shakes were ordered along with Occupational Therapy, Physical Therapy, Morphine intravenously and orally for pain, Ascorbic Acid, Multivitamin for nutritional supplement, and Social Work for discharge planning. Patient #1 sustained a partial thickness burn to the right side of the chest wall with initial debridement and dressing changes with Xeroform and Bacitracin, first degree burns to the right shoulder and right hip, full thickness skin loss due to third degree burn not otherwise specified of the chest wall, excluding breast and nipple and partial thickness burn to the chest wall.

On 10/18/21 at 10:42 AM, the Chief Nursing Officer (CNO) stated he was aware of the incident resulting in patient #1 burns. The CNO said the hospital did not have a policy for heat application. "The hospital follows the Lippincott Manual, and the orientation program provides hands on education on how to access the hospital computer system for policy and procedures. He then stated the RN Job Description indicated the RN had knowledge and is aware they are responsible for all staff working under their license.

On 10/18/21 at 11:30 AM, the Risk Manager (RM) stated that she had conducted the investigation for patient #1 burns. She stated she had interviewed Nurse Technician (NT) B who was assigned to patient #1 on 9/20/21. The RM disclosed that NT B had only worked at the hospital for 20 days and 5 days of the 20 days she was on orientation. The RM stated that NT B had informed Registered Nurse (RN) A that patient #1 had discomfort in her right neck/shoulder and was requesting heat application. RN A was in the middle of her medication administration and indicated to the NT to go ahead and apply heat to patient #1's right shoulder. The RM confirmed NT B had stated she had cut corners because it was taking too long to get hot water so she obtained two plastic ice bags and filled them with hot water from the coffee maker. She then wrapped the plastic bags containing hot water in towels and placed them on the patient. The RM shared that NT B had stated, "I went for the fastest way to accommodate the patient's request." The RM then explained that she had interviewed RN A who was assigned to patient #1 on 9/20/21. "RN A was a travel nurse on a 13-week contract with the hospital." The RM said RN A explained she was in the middle of her medication administration when NT B requested heat therapy for patient #1. RN A assumed that because NT B was a hospital employee, and she knew what to do. RN A informed the RM that she knew she needed a physician order to remove something from the Pyxis System (KPad for heat therapy) and getting a physician order would take time away from her routine. The RM then explained that heat application is not a required competency for the NT or RN, and the hospital did not have a policy for heat therapy.

On 10/18/21 at 2:45 PM, patient #1 stated she had just returned from being at a burn unit at another hospital because the nurse had put hot water from the coffee maker into a plastic bag and then placed the bag on her right shoulder. She explained the bag with the hot water burst opened, spilled down her right side and she was burned on her right neck, shoulder, chest, breast, stomach and side. She said, "It hurt and I could not get the hot water off of me fast enough."

On 10/19/21 at 10:10 AM, the Executive Director of Quality (EDQ) stated the only nurses' note for patient #1's hot water burns was on 9/20/21 at 5:44 PM. The EDQ said, "There was no other assessment or documentation for skin or pain in the medical record."

On 10/20/21 at 10 AM, an observation of the fourth-floor coffee machine water temperature was conducted with the Registered Dietitian, Chief Nursing Officer (CNO), Quality Manager (QM), Risk Manager (RM) and the Executive Director of Quality (EDQ). The coffee maker water was run through the machine and on the second run through the water was temperature was 192 degrees.

On 10/20/21 at 11:30 AM, the Wound Care Program Coordinator (WCPC) was made aware that patient #1's burns had been caused by hot water and he had completed her assessment and all of her daily burn treatments. The WCPC explained she sustained first degree and second degree burns to her right neck, shoulder, chest, breast, nipple, and flank. The WCPC said, "The burns covered 4.5% of her body." He voiced that she initially experienced pain and had pain during her burn treatments. She was evaluated by a burn physician and the decision was made to transfer her to a local acute care hospital burn unit for care and treatment. The WCPC explained her burns were still in the inflamed stage, that an enzymatic was currently being used for debridement, and that she developed scar tissue. The WCPC said, "She still has two small areas on her chest and an area on her breast which have not healed, and the plan is for her to follow-up with the [acute care hospital's] burn physician, and to continue treatment at our hospital's outpatient wound center."

On 10/20/21 at 1:25 PM, interviews were conducted with the Manager of Education and the Senior Professional Development Specialist/Education. They confirmed the process for contracted licensed nurses, the contract was accepted by the CNO, they had online education, clinical orientation in person, two eight-hour classes for healthcare record training, and floor orientation on shift with another nurse. Review of RN A's Medical-Surgical/Telemetry RN Job Description, signed and dated 4/28/21, read, "Position Summary: The Registered Nurse holds shift accountability for providing care to patients by utilizing the Nursing Process in accordance with the state Nurse Practice Act and Facility policy and procedures. The registered nurse demonstrates critical thinking skills, scientific judgement and leadership in the anticipation and planning for safe delivery of care.... delegates patient care priorities commensurate with education and experience of the staff available, provides direction and supervision of assigned personnel delivering patient care . . ."

On 10/20/21 at 2 PM, the CNO stated that he is responsible for the entire nursing department. He said the nurse is responsible for patient assessments for the development of the patient's plan of care and communicating this information to the patient's physician. "[RN A] did not handle the situation for [patient #1's] care and services."

The hospital report provided by the RM reflected that (1) there was no hospital standard for the application of heat for comfort, (2) there were inconsistent methods used by clinical staff to apply heat for comfort, (3) there were barriers to ready access to KPad (4 step process), (4) there was a lack of knowledge of staff concerning the use of heat for comfort (i.e. is an order required) and failure of staff to verify the planned method to apply heat for comfort. There was no documentation that the facility identified the licensed nurse failed to perform a nursing assessment for a patient with a change of condition (pain/discomfort). The nurse failed to notify the physician of a patient's change of condition, and treatment modality (heat therapy) was determined and provided to a patient by an unlicensed staff member. As a result, patient #1 experienced unnecessary excruciating pain, physical trauma, transfer to a burn unit, separation from family members and extended hospitalization for which she was not admitted with. The corrective actions documented (1) staff notified that hot water from the coffee machine is NOT to be used for heat therapy or comfort at any time, (2) create and implement Hospital Policy/Procedure regarding the use of heat and cold for therapy and comfort with education regarding policy and process, (3) verify methods used by staff to apply heat for comfort, (4) reassess ready access to KPad to assure ability to use timely and with fewer steps and (5) need for clear and complete communication between staff when determining ANY plan of patient care is essential to patient safety in shift huddles at least weekly. The corrective actions did not include education for licensed nurses to conduct a nursing assessments for a patient with a change in condition and notification of physician of patient change in condition. The hospital did not have a policy for heat application at the time of the survey.

"The initial nursing assessment . . . involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected. Critical thinking skills applied during the nursing process provide a decision-making framework to develop and guide a plan of care for the patient incorporating evidence-based practice concepts. . . ." (National Center for Biotechnology Information, U.S. National Library of Medicine, retrieved 10/30/2021).

Review of RN A's Agency Contract, not dated, read, "[Agency Name]...The orientation should help you comply with safe patient practices . . .To minimize unexpected incidents, [Agency Name] educates its employees using programs designed to meet National Patient Safety Goals and Performance Improvement Measures....[Agency Name] must be notified immediately of any incidents . . . patient injuries . . . failure to perform duties at expected levels . . .and/or any other adverse event . . ."

RN A's time clock punches reflected that RN A was allowed to work 9 other shifts (9/25/21, 9/26/21, 9/30/21, 10/01/21, 10/03/21, 10/08/21, 10/09/21, 10/12/21 & 10/14/21) after the event related to patient #1's hot water burns.

"Thermal burns occur when hot metals, scalding liquids, steam, or flames come in contact with your skin." (WebMD 10/30/2021). There are three types of thermal burns: First-degree burns . . .This minor burn affects only the outer layer of the skin (epidermis). It may cause redness and pain. Second-degree burns . . .This type of burn affects both the epidermis and the second layer of skin (dermis) . . . Third-degree burns . . . This burn reaches to the fat layer beneath the skin . . . First degree burns only affect the outer or top layer of the skin. The skin may be red and painful but won't have any blisters. A second degree burn the outer layer of the skin as well as the dermis (the layer underneath) has been damaged. The skin will be bright red, swollen, and may appear shiny and wet. You will see blisters and the burn will hurt to the touch. Superficial second-degree burn, only part of the dermis is damaged. You won't have scarring. A deep partial thickness burn is more severe. It may leave a scar or cause permanent change in the color of your skin. Third degree burn, sometimes called a 'full thickness burn' . . . destroys two full layers of your skin. Instead of turning red, it may appear black, brown, white or yellow. It won't hurt because this type of burn damages nerve endings." (healthjade.net/thermal-burn, retrieved 10/30/2021).