HospitalInspections.org

Based on record review and interview, the hospital failed to:

A. Recognize eschar to buttock in patient # 9 resulting in patient not receiving timely or appropriate wound care thereby causing the wound to deteriorate. (See Tag A-0145)

Based on record review and interview, the hospital failed to provide a accurate assessment of Patient # 9 necrotic sacral ulcer.

This failed practiced resulted in patient # 9 not receiving timely or appropriate wound care thereby causing the wound to deteriorate.

Findings:

A policy titled "Abuse/Neglect/Abandonment of Patients" said neglect includes an act or omission such as the failure to provide adequate health care to a patient.

Policy titled "Wound Care Policy" said upon admission or at any time during hospitalization, if there are any abnormalities in skin assessment, a Wound Care Assessment Progress Note will be initiated and will be placed in the MAR.....the medication nurse or designee will reassess the wound/bruise/decubitus at least daily.

Patient # 9

~ A document titled "Nursing Assessment" completed on 08/02/17 for patient # 9, the day of admission showed Staff L charted "black, old bruise to buttocks.

~ A document titled "History and Physical Examination" dictated on 08/03/17 at 1:18 pm by Staff L for patient # 9 showed documentation of large scab and abrasion on patient's left elbow and multiple bruises on upper extremities bilaterally. Patient refused genital/rectal examination. There was no documentation of wound to buttock.

~ A document titled "Nursing Flow Sheet/Progress Note" showed no abnormalities on skin assessments from 08/03/17 to 08/19/17.

~ An incident report showed patient was sent out for respiratory distress to a nearby hospital on 08/19/17.

~ A document titled "Discharge Summary" dictated on 08/19/17 at 10:46 am showed no documentation of wound to buttock.

~ History and physical dated on 08/19/17 from the nearby hospital showed documentation of large necrotic sacral ulcer on buttock.

~ A document titled "History and Physical Examination" completed on 08/25/17 by Staff Q showed documentation of "gluteal wound, not really stageable due to eschar tissue and covering...it is not open....we will continue dressings....will keep wound clean and dry."

On 12/15/17 at 1400, Staff K stated "it wasn't a decub or eschar. There wasn't any sloughing or open skin, but it was black. With this guy he actually sat down so I could visualize better."

On 12/14/17 at 1:11 pm, Staff B stated "the nurses are not assessing right. Assessments must change. That is why I am here."

Based on record review and interview, the hospital failed to:

A. Recognize and provide treatment to eschar on buttock in patient # 9. This failed practice resulted in the RN not providing patient # 9 with timely or appropriate wound care thereby causing the wound to deteriorate. (See Tag A-0395)

B. Recognize a change in condition for 4 of 20 patients (Patients # 7, 8 & 13) the geriatric psych unit. This failed practice resulted in the RN not recognizing signs and symptoms when patients are declining and patients being transferred to a nearby acute care facility. (See Tag A-0395)

C. Reassess patient # 3 & 8 for pain. This failed practice resulted inadequate pain control and relief. (See Tag A-0395)

Based on record review and interview, the hospital failed to ensure an RN accurately assessed patient buttock wound with eschar, change in condition and reassess patients with pain for 5 of 20 records reviewed (Patient # 3, 7, 8, 9 & 13) in the geriatric psych patients.

This failed practice resulted in deterioration of patient # 9's wound and had the potential for serious harm due to lack of assessments and decreased quality of care.

Findings:

A. Recognize buttock wound with eschar for patient # 9

See Tag A - 0145 for patient # 9

B. Change in Condition of geriatric psych patients

~ A policy titled "Assessment and Re-Assessment" said reassessment of the patient's progress is ongoing....if significant change occurs in a patients status the RN must assess the patient, and notify the physician and document.

Patient # 7

~ A record review showed an admission on 07/26/17 with diagnosis of Delusions.

~ A document titled "History and Physical Examination" dictated on 07/27/17 at 6:12 pm, Staff Q documented past medical history positive for cancer, chronic obstructive pulmonary disease, and coronary artery disease with a pacemaker placement. History of deep vein thrombosis, hypertension, and benign prostatic hypertrophy.

~ A document titled "Nursing Flow Sheet/Progress Note" showed respiratory documentation of the following:

07/22/17: non-applicable
08/01/17: non-applicable
08/02/17: blank

~ A review of vital sign records showed the following:

08/01/17 6:00 oxygen saturation 97% on 2 liters of oxygen
08/01/17 4:00 pm oxygen saturation 92% on 2 liters of oxygen
08/02/17 at 4:00 pm oxygen saturation 93% on 2 liters of oxygen

~ On 08/03/17 at 12:00 am, Staff D documented "patient resting in bed with eyes closed. Respirations even and unlabored. No signs of distress noted. Will monitor for safety and comfort level."

~ Contrary to Staff D documentation of "respirations even and unlabored, no signs of distress noted". The patient's started declining on 08/02/17 at 4:00 pm oxygen saturation of 93% on 2 liters of oxygen.

~ On 08/03/17 at 9:00 am Staff L documented patient received in day area. Noticed having labored breathing oxygen saturation 77% and oxygen 3 liters nasal cannula on. Notified Staff O and Q. Vital signs blood pressure 136/78, heart rate 92, respirations 18 and oxygen saturation 77%. Patient is transported to a nearby hospital.

~ On 08/03/17 at 12:30 pm, Staff L documented "patient is discharged to nearby hospital. Patient admitted due to possible congestive heart failure and oxygen saturation 77%."


Patient # 8

A review of record showed patient # 8 was admitted on 08/13/17 with diagnosis of Major Depressive Disorder, Bipolar Disorder, Recurrent Severe Suicidal Ideation. Patient was on Lasix 40 milligrams and Potassium 20 milli equivalents daily.

On 09/02/17 at 3:10 pm, Staff L documented patient was "stuttering and had uncontrollable shakes. Med compliant. Had issues with eating or drinking due to shaking so bad."

~ A record review showed no Nursing Flow Sheet/Progress Note for 09/03/17. The Nursing Flow Sheet/Progress Note for 09/02/17 has progress notes dated 09/03/17.

~ On 09/03/17 at 7:55 am, Staff P ordered a Complete Blood Count, Complete Metabolic Profile, Urine Analysis and Lamictal level.

~ On 09/03/17 at 9:00 pm, Staff L "patient up in wheelchair. Very anxious, shaking so bad. Attend group, affect flat."

~ On 09/04/17 at 1:00 am, Staff L "pt resting with eyes closed. Will continue to monitor for safety."

~ On 09/04/17 at 11:37 am, lab sheet documentation showed blood urea nitrogen and potassium called to Staff U.

~ On 09/04/17 at 2:20 pm, Staff T "patient in dayroom with tremors. Lab called staff and reported elevated potassium of 7.1."

~ On 09/04/17 at 2:30 pm, Staff T wrote telephone order for a transfer to a nearby hospital for altered level of conscious due to increased potassium levels.

~ A document titled "Discharge Summary" on 09/05/17 at 12:37 pm, Staff O documented in discharge summary "I thought maybe she is having extrapyramidal symptoms, therefore, I discontinued the Abilify. Later on, patient was also seen by our consultant and he had recommended that patient to the nearest emergency room, which she did and it was determined that patient has hyperkalemia and was admitted to the regular medical floor."

On 12/12/17 at 1:14 pm Staff B said the nurse should have called the doctor on 09/02/17 when patient starting showing signs and symptoms.

On 12/14/17 at 1:11 pm, Staff B stated the nurses are not assessing right. Assessments must change. That is why I am here.

Patient # 13

~ A review of record for patient # 13 showed registered nurses documented "unable to assess due to agitation" for the following dates: 09/08/17, 09/14/17, 09/18/17, 09/19/17 and 09/20/17 (total 5 days of the 23 day stay).

~ A document titled "History and Physical Examination" dictated on 09/09/17 at 8:20 am Staff M documented patient with trace edema in bilateral lower extremities and slightly jaundiced.

~ A document titled "Nursing Flow Sheet/Progress Note" showed no abnormalities on all sections from 09/09/17 to 09/23/17.

~ On 09/30/17 at 2:15, Staff C documented "patient fell over, injury to coccyx". There was no description of the gluteal injury/laceration on the nursing assessment. Patient was transferred to a nearby hospital due to a post fall gluteal laceration requiring 19 sutures.

~ On 10/01/17 at 6:15 am, Staff E reported the following vital signs 103/58 (blood pressure), 110 (pulse), 20 (respirations), 93% (oxygen saturation) and 101 (temperature) to Staff J.

~ On 10/01/17 at 8:40 am, Staff E documented an order from Staff J to send to a nearby hospital. Patient was admitted to intensive care at a nearby hospital with a diagnosis of sepsis.

On 12/14/17 at 1:11 pm, Staff B stated the nurses are not assessing right. Assessments must change. That is why I am here.

On 12/14/17 at 1:30 pm, Staff B stated the nurses should complete the Nursing Flow Sheet/Progress Note every 24 hours. The nurses decided to do a narrative on patients flowsheet.

C. Reassess patients for pain

~ A policy titled "Management of Pain" said patients have the right to appropriate assessment and management of pain....nurse documents the patient's response to pain treatment on the Medication Administration Record (MAR) or in the progress notes.

Patient # 3

~ A review of document titled "Observations recorded at Med Administration" showed no post evaluation of Oxycodone for the following days on the following days:

~ A review of record showed patients pain level was not reassessed after administration for the following dates:

08/03/17 at 7:36 am with pain level of 8
08/03/17 at 1:06 pm with pain level of 8
08/03/17 at 7:10 pm with pain level of 8
08/05/17 at 1:17 pm with pain level of 8
08/10/17 at 11:23 am with pain level of 9

Patient # 8

~ A review of document titled "Observations recorded at Med Administration" showed no evaluation of Tramadol for the following days:

~ A review of document titled "Observations recorded at Med Administration" showed no evaluation of Tramadol being effective for the following days:

~ A review of document titled "Nursing Flow Sheet/Progress Note" showed no evaluation post administration of Tramadol for the following days:

08/15/17 at 12:08 pm with pain level of 5
08/16/17 at 8:39 am with pain level of 7
08/17/17 at 6:40 am with pain level of 9
08/22/17 at 2:39 pm with pain level of 7
08/26/17 at 10:39 am with pain level of 6


On 12/14/17 at 12:32, Staff B stated a post evaluation of pain would be expected after administration of medication.

Based on record review and interview, the hospital failed to ensure healthcare providers completed documentation into the patient's medical record necessary for patient safety, quality of care and continuity of care among providers.

This failed practice resulted in the potential for one patient (Patient # 9) to not have eschar to buttock assessed, potentially four patients (Patient # 7, 8, 9, & 13) having a change in clinical condition and four patients (Patient # 7, 8, 9, & 13) being transferred to an acute care facility for treatment.

Findings:

A policy titled "Medical Records - Documentation Requirement" said the Registered Nurse should be documenting on acute units as least daily, and as needed to address any unusual events, and in Residential Treatment Center (RTC), a weekly summary shall be completed.

A. Recognize eschar to buttock in patient # 9 . (See Tag A-0145)

B. Change in condition patient and transfer to an acute care facility for 4 of 20 records reviewed (Patient # 7, 8, 9, 13). (See Tag A-0395)