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Based on observation, interview, and document review, the hospital failed to ensure that nursing care interventions were planned and implemented to protect patient safety, in 1 of 11 patients reviewed (P1), who sustained a second-degree burn from hot coffee due to impaired cognition in the postoperative phase of care. Findings include:

P1's preoperative history and physical (H&P), dated 05/15/13, indicated that P1 was evaluated for a planned surgical procedure on 05/29/13. The H&P indicated that P1 was alert with appropriate orientation, presented no surgical risks, and elected to undergo surgery. P1's surgical record indicated that P1 was admitted for hospitalization on 05/29/13 at 7:45 a.m. for a total joint arthroplasty of the left knee. Preoperatively, P1 understood the procedure and signed his own informed consent form.The operative report, dated 05/29/13, indicated that P1 tolerated the surgical procedure without any difficulty. P1 had received a peripheral nerve block for the procedure with routine anesthesia medications, such as Versed and Fentanyl. P1 then went to the recovery room in stable condition and was later transferred to a medical-surgical unit on 05/29/13 at 12:30 p.m.

The physician's orders for management of P1's postoperative pain included Morphine Sulfate 2 mg IV every hour as needed for moderate pain or 4 mg IV every hour as needed for severe pain; Percocet 5/325 1 tablet every 6 hours as needed for moderate pain or two tablets every 6 hours as needed for severe pain.

P1's medication administration record (MAR) indicated that at 1:20 p.m. on 05/29/13, P1 received Percocet two tablets 5mg/325 (each tablet) for pain. The day-shift nursing assessment indicated that P1 was alert and oriented.

The nurse's notes at 6:40 p.m. on 05/29/13 indicated that P1 was confused and was trying to pick at his IV, telemetry leads, and gown. P1 was re-directed multiple times. The MAR indicated that at 7:15 p.m. on 05/29/13, P1 received Morphine Sulfate 2mg IV for pain. The nurse's notes at 7:30 p.m. on 05/29/13 indicated that P1 was very anxious and confused. P1 was "seeing beetles." P1 was attempting to pull out the IV and surgical drain. The physician was notified of P1's status and ordered Valium 5mg IV or oral every 6 hours as needed. The MAR indicated that at 7:30 p.m. on 05/29/13, P1 received Valium 5mg orally.
The MAR indicated that at 7:45 p.m. on 05/29/13, P1 received Percocet two tablets 5mg/325 (each tablet) for pain. At 8:30 p.m. on 05/29/13, P1 received Morphine Sulfate 4mg IV for pain. The nurse's notes indicated that at 8:45 p.m. on 05/29/13, P1 continued to have visual hallucinations. The physician was notified of P1's status and ordered a stat dose of "Haldol 1 mg IV now. May repeat in 2 hours if needed." The MAR indicated that at 9:00 p.m. on 05/29/13, P1 received Haldol 1 mg IV. The MAR indicated that at 11:00 p.m. on 05/29/13, P1 received a repeat dose of Haldol 1 mg IV.P1's nursing care plan for 05/29/13 did not include any information about P1's need for Valium or Haldol. The care plan did not address P1's orientation status, hallucinations, or how much staff supervision and assistance P1 required with care. The care plan did not include any interventions regarding P1's safety needs.

The nurse's notes during the night shift of 05/29 - 05/30/13 indicated that P1 had been confused since evening shift and that evening shift had given P1 Haldol with little effect. The MAR indicated that at 12:30 a.m. on 05/30/13, P1 received Morphine Sulfate 4 mg IV for pain. The nurse's notes at 1:35 a.m. on 05/30/13 indicated that P1 remained agitated and was picking at his IV, oxygen tubing, knee dressing, and surgical drain. The MAR indicated that at 4:05 a.m. on 05/30/13, P1 received Morphine Sulfate 4 mg IV for pain and at 4:10 a.m. on 05/30/13, P1 received Percocet two tablets 5mg/325 (each tablet) for pain. The nurse's notes at 5:45 a.m. on 05/30/13 indicated that P1 continued to be confused and agitated. P1 had a bed alarm and "sitter" (a trained volunteer) for safety, as P1 would appear to fall asleep for a few minutes then attempt to get out of bed. P1 continued to pick at his surgical dressing and IV. P1 refused to keep his oxygen on. The MAR indicated that at 5:45 a.m. on 05/30/13, P1 received Morphine Sulfate 4 mg IV for pain.

The nurse's notes at 7:30 a.m. on 05/30/13 indicated that P1 pulled his surgical drain apart and the drain had to be knotted off. The physical therapy progress notes on 05/30/13 indicated that P1 was confused and fell asleep many times during the morning exercise program. The nurse's notes indicated that at 1:30 p.m. on 05/30/13, P1 became extremely agitated and was pulling at his IV and foley catheter. P1 was so agitated, staff could not obtain P1's vital signs. The physician was contacted at 2:00 p.m. on 05/30/13 and ordered one dose of Haldol 5mg IM. The MAR indicated that at 2:20 p.m., P1 received Haldol 5mg IM due to P1's agitated state, but the medication provided little relief. The MAR indicated that at 5:00 p.m. on 05/30/13, P1 received additional Haldol 2mg IV for agitation. The physical therapy progress notes on 05/30/13 indicated that P1 remained agitated in the evening and was unable to participate in physical therapy activities. The MAR indicated that at 8:00 p.m. on 05/30/13, P1 received Haldol 2mg IV for agitation. The MAR indicated that at 9:30 p.m. on 05/30/13, P1 received additional Haldol 2mg IV for agitation.

P1's nursing care plan for 05/30/13 did not include any planned care interventions that pertained to P1's need for safety, due to P1's agitation, restlessness, and state of confusion. Although the nurse's notes for the night shift of 05/29 - 05/30/13 indicated that P1 required a bed alarm and "sitter" for safety that shift, the nursing care plan did not reflect whether these interventions were included as a continuum of care. The nursing care plan did not address P1's orientation status or how much staff supervision, frequency of monitoring, or assistance P1 required with care.

The nurse's notes for the night shift of 05/30 - 05/31/13 indicated that P1 had been resting until 1:30 a.m., at which time P1 began pulling on his catheter. After P1 was re-positioned and re-directed, P1 rested comfortably. At 5:00 a.m., P1 experienced "mild" agitation when he was re-positioned. P1 was oriented to "self" only.

The nurse's notes at 8:00 a.m. on 05/31/13 indicated that P1 was restless at times. P1 was alert and oriented to "person" only. The nurse's notes at 8:30 a.m. on 05/31/13 indicated that Nurse (H)/RN entered P1's room to assist P1 with breakfast and coffee was spilled all over P1's bed, gown, and floor. P1 had a second-degree burn on his chest with skin sloughing. The physician and family were notified of P1's burn. The burn was photographed but the dimensions of the burn were not documented.

Based on the photographs, P1 sustained the burn in the mid-sternum and the burn extended downward to the upper abdomen. The area of injury consisted of two distinct parts. One part of the burn was approximately 4 inches wide (2 inches on both sides of the sternum) and approximately 3 inches long. The other part of the burn was on the abdomen, directly below the first part of the burn, and was approximately 2 inches wide by 2 inches long.
An incident report, dated 05/31/13 at 8:15 a.m., indicated that P1's breakfast tray had been delivered by the dietary department and placed on the patient's bedside table, "not within reach of patient." Before Nurse (H)/RN had the opportunity to "assist patient with tray, he had spilled coffee on himself sustaining second-degree burn to chest."
The physician's orders indicated that Silvadene cream was ordered to treat the burn. After P1 sustained the burn on the morning of 05/31/13, documentation in the nurse's notes and therapy progress notes throughout the remainder of 05/31/13 indicated that P1 was restless, confused, hallucinated, and was not appropriate for therapy because P1 was unable to follow directions.

The physician progress notes, dated 05/31/13, indicated that P1 had "problems with agitation presumed secondary to anesthetics and pain medications. This has been addressed with several doses of Haldol, both IV and IM. The patient did spill some hot coffee over his chest and has a small burn area as a result. He remains fairly confused but less agitated today. Patient's course has been complicated by delirium."

The discharge summary, dated 06/02/13, indicated that P1's final diagnosis was advanced degenerative arthritis of the left knee with an operative procedure for total joint replacement arthroplasty of the left knee. P1's secondary diagnosis was "postoperative confusion/disorientation, resolving at time of discharge." P1's discharge medication orders, dated 06/02/13, included prescriptions for Norco to manage pain and Silvadene cream 30 mg to be applied daily to the burn on the chest. P1 was discharged to a rehabilitation facility.

Obsevations on the Medical-Surgical Unit on 07/29/13 at 8:40 a.m. and 10:30 a.m. revealed that patients have a private room for recovery during postoperative care. Patient rooms are designed with the patient's bed, bedside table, and medical equipment positioned on one side of the room, and a five-foot long counter with a sink on the opposite side of the room. The sink counter is nine feet away from where a patient is positioned in bed. The patient's toilet and tub are located in a separate room.

Nurse (H)/RN was interviewed on 07/29/13 at 12:50 p.m. Nurse (H)/RN stated that s/he was assigned to P1's care on the morning of 05/31/13, when P1 sustained a burn to the chest. S/he had not been assigned to P1's care prior to 05/31/13. S/he received shift report on the morning of 05/31/13 and was told that P1 had periods of confusion and couldn't follow directions. S/he was told that P1 had a bed alarm because P1 was at risk for falls. S/he was not told that P1 had required several doses of Haldol for agitation the previous evening shift. S/he assessed P1 at 8:00 a.m. on 05/31/13. P1 had a Falling Star posted on the outside of P1's door, which meant that P1 was at high risk for potential falls and needed assistance to get out of bed. P1 was oriented to self only. P1 didn't know that s/he was in the hospital. P1 was restless. Shortly after 8:00 a.m. (exact time unknown), Nurse (H)/RN passed by P1's room. P1 was eating toast at the bedside. Nurse (H)/RN proceeded to check another patient. About 30 minutes later, Nurse (H)/RN entered P1's room to assist P1 with breakfast. P1 was awake. P1 had spilled coffee all over his bedding and gown. P1 had a baseball-size burn on his/her chest that was red and blistered. Nurse (H)/RN applied a cold compress to the area and notified the physician and family member of the burn. The physician ordered topical Silvadene cream to treat the burn. Nurse (H)/RN also notified the Dietary Department to place P1's food trays on the counter in the future, which is ten feet from the patient's bed, rather than delivering P1's tray to P1's bedside. Nurse (H)/RN was again assigned to P1's care on 06/02/13, the day of P1's hospital discharge. On 06/02/13, P1 remained confused. P1 was oriented only to his name.

Nutrition Services Aide/(J) was interviewed on 07/29/13 at 2:30 p.m. Nutrition Services Aide/(J) stated that s/he delivers all patient trays to the patient rooms. Prior to tray delivery, Nutrition Services Aide/(J) checks all the dietary kardexes to ensure the correct diet is being served to the patient as well as any specific instructions from nursing regarding staff assistance the patient requires. P1's kardex had no special instructions from the nursing department. Nutrition Services Aide/(J)'s routine when delivering patient trays is to knock on the patient's door, identify him/herself as being from dietary, ask the patient his/her name, and ask the patient where the patient would like their food tray placed, which is generally at the patient's bedside. If the patient is sleeping, Nutrition Services Aide/(J) places the patient's tray on the counter which is about ten feet from the patient's bedside. Nutrition Services Aide/(J) then informs the nursing staff that s/he has placed a patient's food tray on the counter, which is out of the patient's reach. On 05/31/13, Nutrition Services Aide/(J) delivered P1's breakfast tray to P1's room around 8:00 a.m. P1 was awake and identified himself. Nutrition Services Aide/(J) placed P1's breakfast tray on his bedside table, consistent with dietary practice.

Nurse Manager (B)/RN was interviewed on 07/29/13 at 3:05 p.m. Nurse Manager (B)/RN stated that a patient's initial eating assessment is completed by a registered nurse. The information collected is entered into a computer and called to the dietary department. The dietary department maintains a kardex/care plan which indicates each patient's specific dietary needs, requirements, and meal assistance. Tray service and tray delivery to patient rooms stems from the kardex/dietary care plan. If a patient has a change in condition after the initial nursing assessment, nursing staff communicate the need to alter the dietary care plan at the time of tray service, "in the hallway." Nurse Manager (B)/RN acknowledged that the hospital did not have a formal communication system with the dietary department to capture patient changes in condition, that may affect a patient's ability to self-manage a meal.

Family member/(K) was interviewed on behalf of P1 on 07/26/13 at 10:35 a.m. Family member/(K) stated that prior to hospital admission, P1 lived alone at home. P1 was alert, oriented, and made independent decisions. After P1's surgical procedure, P1 had extreme confusion and was completely disoriented during P1's stay on the medical-surgical unit. Due to P1's surgical procedure, P1 wasn't allowed up on his own and P1 constantly tried to get out of bed. P1 was very restless and agitated. Hospital staff told Family member/(K) that P1's change in normal orientation status resulted from difficulty with medications P1 was receiving. Family member/(K) talked to Social worker/(I) on the morning of 05/31/13 (exact time unknown) as part of the discharge planning process, to determine P1's recovery placement after hospital discharge. Social worker/(I) informed Family member/(K) that P1 was not appropriate for a swing bed placement because P1 required more supervision than could be provided in that setting, due to P1's agitation and confusion. After Family member/(K)'s conversation with Social Worker/(I) on 05/31/13, Family member/(K) was later notified on 05/31/13 that P1 spilled hot coffee on her/himself and sustained a burn to the chest. Family member/(K) expressed concern that hospital staff did not provide the necessary supervision and assistance with care P1 needed, such as helping P1 with his/her breakfast tray, even though it was known that P1 was confused and agitated from medications.

Social worker/(I) was interviewed on 07/29/13 at 2:00 p.m. Social worker/(I) stated s/he met with two of P1's family members on the morning of 05/31/13 regarding P1's discharge placement plan. Social worker/(I) could not recall what time s/he met with P1's family on 05/31/13 and Social worker/(I) failed to document the time of the meeting. Social worker/(I) stated that P1's family was upset that P1 didn't qualify for a swing bed placement because P1 wasn't recovering as anticipated. P1 was very confused, wasn't actively participating in physical therapy, and was too dependent in activities of daily living. P1 wasn't appropriate for a swing bed placement.

The hospital's policy on Admission Assessment and Care Planning, revised October 2011, indicated "The assessment and care planning process will be individualized...The RN is responsible for the nursing assessment. The scope of the professional nursing assessment will include the collection and analysis of information to determine the patient's response to actual or potential health problems. The admission assessment will include a screening process for the purposes of identifying functional, educational, psychosocial, nutritional, and/or discharge planning needs. Information will be integrated through the assessment process and utilized to assign priorities for interventions and to formulate a problems list and outcomes in an individualized plan of care. The need for reassessment will be determined by the patient's diagnosis, care setting, desire for care, response to treatment, and consent for treatment as outlined in unit specific scope and standards of practice. Reassessment will focus upon abnormals that are identified in a prioritized problems list incorporated in the plan of care."

The hospital's policy on Standards of Nursing Care for Medical/Surgical Nursing Unit, reviewed November 2012, indicated "The patient will receive care that reflects an ongoing process of management of their health status. The patient will be assessed on admission. This assessment will be implemented by an RN in a caring and professional manner within 24 hours of admission. Re-assessment shall occur every shift and as per patient condition. The patient will have nursing diagnoses appropriately identified. The patient can expect the nurse to identify: Risk for impaired verbal communication...Risk for impaired physical mobility...Risk for alteration in nutritional status...Risk for self-care deficits/personal hygiene needs...Risk for anxiety, depression, denial, confusion, and/or altered thought processes. The patient's individualized plan of care will be based on problems/needs identified in the assessment by the registered nurse. The patient will receive ongoing evaluations of the effectiveness of the care provided during their stay. The patient can be expected to be evaluated for all potential or actual problems/needs noted in the plan of care. The patient can expect to receive care in a safe environment."

The hospital's policy on Patient Identification for Meal Service, reviewed July 2012, indicated "Prior to each tray or meal service, a label from Meditech System will be printed to identify the patient and diet order. The printed meal label is to be attached on each tray to identify the patient and diet order. Upon delivery of a tray to a patient, Nutrition Staff to ask for the patient name and birthdate before providing patients their tray."