HospitalInspections.org

Based on document review and staff interview it was determined the facility failed to obtain appropriate consent for treatment, per policy, for two (2) of two (2) patients whose medical records revealed them to be incapacitated (Patients #1 and 4). This failure impinges upon the right of a patient to have a trusted/known designee make health-care decisions on their behalf.

Findings include:

1. Review of the policy entitled, "Patient Consent", last revised 11/2011, under the heading 'Incapacitated Patients', revealed it states, in part: "When a patient is or becomes incapacitated, the attending physician or advanced practice nurse, in collaboration with the attending physician and/or social worker, will make reasonable inquiry as to the availability and authority of a guardian..." It further states under the heading 'Nursing Responsibility': "Determine who is legally responsible and allowed to sign the consent, in accordance with this policy." It further states, in the event emergency treatment is required without delay, "Hospital personnel and the physician must document in the medical record the medical need for proceeding with treatment without consent and the inability to contact the appropriate person."

2. Patient #1's medical record was reviewed on 1/4/16. It revealed the patient was a resident of a long-term care psychiatric facility and had accompanying documentation of an assigned Health Care Surrogate (HCS), including contact phone numbers, in his chart at the time of his arrival to the Emergency Room (ER) on 4/10/15. No documentation of a consent to treat was located in the medical record. No documentation was found of the need for emergency treatment, or of any attempts made to contact the HCS.

The above findings were reviewed with the Vice President (VP) of Clinical Operations on 1/6/16 at 2:45 p.m., at which time she agreed the facility was unable to locate any consent to treat in Patient #1's medical record and no documentation was found in the medical record to indicate attempts were made to contact the HCS or emergency medical treatment was required without delay.

3. Patient #4's medical record was reviewed on 1/5/16. It revealed the patient was a resident of a long-term care psychiatric facility and had accompanying documentation of an assigned HCS as a ward of the state. Review of his consent for treatment revealed a signature at the bottom of the page, in the area designated for "Patient/Responsible Party", with the initials "RN" noted following the signature. No documentation was noted related to emergency treatment or any attempts to obtain consent from the HCS.

The above findings were reviewed with the VP of Clinical Operations on 1/5/16 at 1:40 p.m., at which time she stated she had verified with the Emergency Department (ED) Nurse Manager that the signature on Patient #4's consent was that of an ED nurse. She agreed this was not in adherence with facility policy and further agreed no documentation could be found indicating the patient had required emergency treatment without delay or that attempts had been made to obtain consent from the HCS.

A. Based on document review, record review and staff interview it was determined the facility failed to ensure nursing care provided wound care to patients in accordance with physician's orders, per policy, for one (1) of four (4) patients receiving wound care (Patient #1). This failure has the potential for patients to receive inappropriate and/or inconsistent care, with possible negative outcomes.

Findings include:

1. Review of the policy entitled, "Nursing Care Guidelines - Integumentary", last revised 8/2012, under the heading 'Procedure: F' revealed it states, in part: "Perform appropriate wound care as identified by the physician."

2. Patient #1's medical record was reviewed on 1/4/16. It revealed the patient was admitted on 4/10/15 through the Emergency Room (ER) to the Acute Care unit. The document entitled, "Progress Note ER Note", dated 4/10/15, included the entry: "Superficial skin breakdown epidermal exfoliation over coccyx (tailbone) 3X3 cm (centimeters) covered with protective barrier".

Review of Patient #1's physician's orders throughout his hospital stay revealed there were no orders for specific dressings or treatments for wounds.

Further review of Patient #1's medical record revealed multiple nursing notes as follows: Physical Assessment note dated 4/12/15, time 4:13 a.m., included the entry: "Pt has wounds on R foot, L hip and coccxy, all dressings are cdi (clean, dry, intact)." Physical Assessment note dated 4/12/15, time 7:50 a.m., included the entry: "multiple wounds with dressings." Physical Assessment note dated 4/13/15, time 12:00 p.m., included the entry: "Dressing to the outer right foot and right hip C/D/I." Physical Assessment note dated 4/14/15, time 8:00 a.m., included the entry: "Dressings: 6X6 Mepilex on each hip, Coccyx Alevyn over buttocks, 3X3 Alevyn on right ankle. All dressings dry and intact. Changed." Physical Assessment note dated 4/14/15, time 10:38 a.m., included the entry: "Alevyn replaced...Redness noted on left hip, replaced 6X6 Mepilex...Abrasion on inner left calf, left open to air. 3X3 Alevyn in place on outer right foot, dry and intact."

The above findings were reviewed with the Nurse Manager of the Acute Care/ICU on 1/4/16 at 2:45 p.m., at which time she agreed the nursing wound care interventions as documented were being performed without physician's orders.

3. An interview was conducted with the Physician Liaison on 1/6/16 at 11:12 a.m. He stated he was the Chief of Staff at the time of Patient #1's admission. He stated the facility policy and expectation was for nursing to perform wound care in accordance with physician's orders.

B. Based on record review and staff interview it was determined the facility failed to ensure nursing staff obtained daily weights for four (4) of four (4) patients for whom daily weights were ordered (Patients #4, 5, 6 and 9). This failure has the potential for changes in a patient's health status to remain undetected and untreated, leading to possible negative outcomes.

Findings include:

1. Patient #4's medical record was reviewed on 1/5/16. Physician's orders included the entry "Daily weights". Review of all documents entitled, "Nursing Asst Admission Flowchart", which includes vital signs and weights, for all dates of the patient's hospital stay revealed no weights were documented for 1/2, 1/3 or 1/4/16.

The above findings were reviewed with the Vice President (VP) of Clinical Operations on 1/5/16 at 1:40 p.m., at which time she agreed the weights had not been obtained daily as ordered.

2. Patient #5's medical record was reviewed on 1/5/16. Physician's orders included the entry "Daily weights". Review of "Nursing Asst Admission Flowchart" entries for all dates of the patient's hospital stay revealed no weight was documented for 1/4/16.

The above findings were reviewed with the Nurse Manager of the Acute Care/ICU on 1/5/16 at 3:05 p.m., at which time she agreed the weight had not been obtained daily as ordered.

3. Patient #6's medical record was reviewed on 1/5/16. Physician's orders included the entry "Daily weights". Review of "Nursing Asst Admission Flowchart" for all dates of the patient's hospital stay revealed no weights were documented for 1/2 or 1/3/16.

The above findings were reviewed with the Nurse Manager of the Acute Care/ICU on 1/5/16 at 3:05 p.m., at which time she agreed the weights had not been obtained daily as ordered.

4. Patient #9's medical record was reviewed on 1/6/16. Physician's orders included the entry "Daily weights". Review of "Nursing Asst Admission Flowchart" for all dates of the patient's hospital stay revealed no weight was documented for 12/13/15.

The above findings were reviewed with the VP of Clinical Operations on 1/6/16 at 2:10 p.m., at which time she agreed the weights had not been obtained daily as ordered.

Based on document review, record review and staff interview it was determined the facility failed to ensure a nursing care plan was developed and kept current, per policy, for two (2) of ten (10) medical records reviewed (Patients #1 and 9). Failure to develop and keep current an individualized plan of care for each patient can result in inadequate or inappropriate care of all patients, with possible negative outcomes.

Findings include:

1. Facility policy entitled, "Nursing Plan of Care", last revised 8/2013, was reviewed on 1/5/16. It states, in part: "All patients shall be assessed on admission, and a written Plan of Care developed and initiated within eight (8) hours of admission by an RN." It further states, in part: "Include Actual and Potential Problems/Needs which are identified based upon assessment/ reassessment", and defines the term "Actual Problem/Need" as "problem/need which exists. Signs and symptoms are present."

2. Patient #1's medical record was reviewed on 1/4/16. It revealed an admission date of 4/10/15 with a primary diagnosis of pneumonia. The documentation accompanying the patient from the Emergency Department entitled, "Progress Note ER Note", revealed, in part: "emaciated...superficial skin breakdown".

Admission assessments by nursing included wound measurements and assessments of multiple areas of skin breakdown. A Care Plan was noted as initiated on 4/10/15 following admission assessment by nursing staff and revealed the entry: "Patient will have labs WNL (within normal limits) by D/C (discharge)." The admitting physician's History and Physical, dated 4/11/15, stated in part: "severe malnutrition...multiple areas of skin breakdown", with plans for interventions noted. No additional entries to the Care Plan were noted by nursing during the patient's hospital stay.

An interview was conducted with the Clinical Coordinator on 1/6/16 at 12:00 p.m., at which time the above findings were reviewed. The Clinical Coordinator stated her expectation for an appropriate Nursing Care Plan based on the assessment of Patient #1's needs should have included goals and interventions related to the Integumentary System (skin), and nutrition.
She agreed the Care Plan as written did not conform to facility policy.

3. Patient #9's medical record was reviewed on 1/6/16, and revealed no care plan had been initiated.

The above record was reviewed with the VP of Clinical Operations on 1/6/16 at 2:10 p.m., at which time she stated she was unable to locate a Care Plan for Patient #9 and agreed this did not conform to facility policy.