HospitalInspections.org
Bringing transparency to federal inspections
WIREGRASS MEDICAL CENTER
PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING
Tag No.: A0130
Based on medical record review, interviews and review of policy and procedure, nursing staff failed to notify Patient Identifier (PI) # 1's family about an accidental coffee spill resulting in injury to PI # 1's skin. This deficient practice affected one of 10 sampled patients.
Findings include:
PI # 1 was admitted to the Senior Care Unit on 10/27/15 with diagnoses to include Alzheimer's Dementia and New onset Behavioral Disturbance due to Organic Brain Disease.
A review of the Wound Assessment Worksheet dated 11/7/15 revealed newly acquired "excoriation" PI # 1's inner thighs (documented by Employee Identifier (EI ) # 5, Licensed Practical Nurse).
There was no documentation in PI # 1's medical record regarding the coffee spill on 11/7/15.
During an interview on 12/14/15 at 2:30 PM a Mental Health Technician (MHT), Employee Identifier (EI) # 1, confirmed PI # 1 requested a cup of coffee during snack time (sometime between 9:00 AM and 9:45 AM on 11/7/15). The MHT stated the cup of coffee sat on the table for "10 to 15 minutes" because staff was searching for a lid for the cup. Staff was unable to find a lid and gave the coffee to PI # 1 without a lid. According to the MHT, approximately ten minutes later she "heard a cup fall" and noticed PI # 1 had spilled the coffee (upper leg area). PI # 1 did not complain of pain. According to the MHT, PI # 1 could hold a cup independently.
During an interview on 12/15/15 at 11:00 AM, a staff RN (Registered Nurse), EI# 2, said a MHT notified her that PI # 1 spilled coffee. When asked if she notified PI # 1's family about the accident the RN said, "no."
A review of the policy, Sponsor Notification, dated 11/2000, revealed the facility will inform the resident (same as patient), consult with the resident's physician and if known, notify the resident's legal representative...when there is:
(a). An accident involving the resident which results in injury and has the potential for requiring physician intervention...
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on medical record review and interviews, the nursing staff failed to assess Patient Identifier (PI) # 1's skin after an accidental coffee spill, notify the Physican about the accident and document the incident in the medical record. This deficient practice affected one of 10 sampled patients.
Findings include:
PI # 1 was admitted to the Senior Care Unit on 10/27/15 with diagnoses to include Alzheimer's Dementia and New onset Behavioral Disturbance due to Organic Brain Disease.
A review of the Wound Assessment Worksheet dated 11/7/15 revealed newly acquired "excoriation" to PI # 1's inner thighs (documented on the evening shift by Employee Identifier (EI ) # 5, Licensed Practical Nurse.)
There was no documentation in PI # 1's medical record regarding the coffee spill on 11/7/15.
During an interview on 12/14/15 at 2:30 PM a Mental Health Technician (MHT), Employee Identifier (EI) # 1, confirmed PI # 1 requested a cup of coffee during snack time (sometime between 9:00 AM and 9:45 AM on 11/7/15). The MHT stated the cup of coffee sat on the table for "10 to 15 minutes" because staff was searching for a lid for the cup. Staff was unable to find a lid and gave the coffee to PI # 1 without a lid. According to the MHT, approximately ten minutes later she "heard a cup fall" and noticed PI # 1 had spilled the coffee (upper leg area). PI # 1 did not complain of pain. According to the MHT, PI # 1 could hold a cup independently.
During an interview on 12/15/15 at 11:00 AM, a staff RN (Registered Nurse), EI# 2, said a MHT notified her that PI # 1 spilled coffee. When asked if she assessed the patient and notified PI # 1's family about the accident the RN said no. EI # 2 said she did not remove the patient's clothing to assess the skin. " I didn't remove (his/her) clothes. Kind of count on night shift to do that when patient is undressed for bed."
ADMINISTRATION OF DRUGS
Tag No.: A0405
Based on medical record review, review of the Medication Administration Record (MAR) and interviews, nursing staff failed discontinue the use of Calmoseptine for Patient Identifier (PI) # 1 after a physician's order was written on 11/8/15 to discontinue the medication (Calmoseptine). This affected PI # 1, one of ten sampled patients.
Findings include:
PI # 1 was admitted to the Senior Care Unit on 10/27/15 with diagnoses to include Alzheimer's Dementia and New onset Behavioral Disturbance due to Organic Brain Disease.
A review of a physician's order written on 11/7/15 at 7:30 PM revealed, Clean excoriated areas to bilateral inner thigh with NS (normal saline)...apply Calmoseptine tid (three times per day)...
A physician's order written on 11/8/15 at 4:10 PM revealed, D/C (discontinue) previous wound care orders (Calmoseptine) to inner thighs.
A review of the MAR revealed Calmoseptine was applied by nursing staff to PI # 1's inner thighs eight times after the medication was discontinued per physician's order on 11/8/15 on the following dates:
11/8/15 at 7:19 PM
11/9/15 at 8:23 AM, 1:43 PM and 7:36 PM
11/10/15 at 7:59 AM and 7:23 PM and
11/11/15 at 8:00 AM and 2:00 PM.
During an interview on 12/16/15 at 11:15 AM the Director of Nursing, Employee Identifier # 4, confirmed Calmoseptine was administered to PI # 1 by nursing staff as documented on the MAR after the medication was discontinued by a physician's order written on 11/8/15.