HospitalInspections.org

Based on observation, interview, and record review, the facility failed to monitor and remove expired supplies from potential use on patients in the Emergency Department (ED). The facility census was 15 patients, ten Swing status and five acute.

Findings included:

Record review of Policy titled "ER Policy for Checking Inventory Outcomes" dated 7/2007, with no revision dates, showed the following:
-Drug and supply outdates will be checked on day shift the last day of the month;
-Restock the expired drugs and supplies as soon as possible after receiving the new stock so that crash carts and other department areas are properly supplies and ready for emergencies.

Observation of the Emergency Department on 5/17/10 at 2:53 P.M., showed four Foley catheters (a sterile tube inserted into the bladder to drain urine) with expiration dates of 12/2006, 3/2010, 3/2004, and 8/2009, located in a storage cabinet adjacent to the nurse station.

During an interview on 5/17/10 at 3:00 P.M., Staff O, Emergency Department Supervisor, confirmed the Foley catheters' expiration dates.

Observation of the ED on 5/18/10 at 9:20 A.M., showed eight sterile examination gloves with an expiration date of 12/31/07 located in room "ER 2", cabinet 70.

Observation of the ED on 5/18/20 at 9:30 A.M., showed three sterile examination gloves with an expiration date of 12/31/07 located in room "ER 1", cabinet 40.

During an Interview on 5/18/10 at 10:00 A.M., Staff O confirmed the expiration dates of the gloves and said policy states supplies should be checked monthly for expiration dates.

Based on observation, interview, and record review, the facility failed to secure emergency medications to prevent unauthorized use by patients, visitors, or staff in the Emergency Department (ED). The facility census was 15 patients, ten Swing status and five acute.

Review of policy "Pharmacy & Ancillary Security" dated 11/21/95 with a revised date of 7/06, showed all medications located in departments outside the hospital pharmacy should be contained in secure, lockable cabinets. In areas not continuously staffed, drug storage cabinets should be locked when left unsupervised (paragraph two).

Observation of the ED on 5/18/10 at 9:15 A.M., showed crash carts (a cart which contains emergency medications, supplies, and equipment) located in patient rooms "ER 1" and "ER 2". The cart has a breakaway integrity seal (a number coded plastic device which breaks when pulled) on the medication drawer. Inside the medication drawer is a removable plastic box and several bags containing emergency medications, also sealed with integrity seals.

During an Interview on 5/18/10 at 9:15 A.M., Staff O, Emergency Department Supervisor, said the crash carts are not locked with any locking mechanism, other than the breakaway integrity seal.

Observation of the ED on 5/18/10 at 9:18 A.M., showed the patient room "ER 2", cabinet 66, contained 2 vials of nitroglycerin tablets (a medication used for patients who have chest pain) in a clear, removable plastic box.

During an interview on 5/18/10 at 10:00 A.M., Staff O said the nitroglycerin was kept in the cabinet so it could be quickly and easily accessible by the staff during an emergency.

Based on observation and interview, and record review, the facility failed to follow standard precautions and use proper hand washing, placing patients, visitors, and staff at risk for infection transmission. The facility census was 15 patients, ten Swing status and five acute.

Findings included:

Record review of the Exposure Control Plan, Bloodbourne Pathogens Final Rule dated 2/10/93 with a revised date of 7/15/04, showed the following:
-the facility observes the practice of "Standard Precautions" to prevent contact with blood and other potentially infectious materials (A. Standard Precautions);
-employees wash their hands immediately after removal of gloves (C. Work Practice Controls);
-following any contact of body areas with blood, employees wash their hands (C. Work Practice Controls);
-gloves are worn when performing vascular access procedures (the insertion of a flexible thin plastice tube, or catheter, into a blood vessel) if contact with blood is anticipated (D. Personal Protective Equipment).

Record Review of the policy "Hand-washing", undated, showed recommended times to wash the hands would be:
-before and after giving cares to a patient (Procedure 3.A.);
-before and after performing invasive procedures (Procedure 3.B.).

Observation of the Emergency Department (ED) on 5/17/10 at 2:10 P.M., showed Staff L, Emergency Medical Technician Paramedic, inserting an intravenous catheter (a device used to administer medication or fluids into a patient's blood system) on patient #19 without wearing gloves.

Observation of the ED on 5/17/10 at 2:19 P.M., showed Staff N, radiology technician, walk into Patient #19's room and place a radiology film cartridge (used for taking xrays of patients) behind the patients back without washing his/her hands. Staff N then removed the cartridge from the behind the patient, left the room, and left the department without washing his/her hands.

Observation of the ED on 5/17/10 at 3:02 P.M., showed Staff N returning Patient #19 to the ED in a wheelchair and assist the patient onto the ED cart. Staff N left the patients room and the department without washing hi/her hands.

During an interview on 5/17/10 at 3:15 P.M., Staff O, Emergency Department Supervisor stated staff are expected to wash their hands before and after direct patient contact. Staff O also states staff are expected to wear gloves when there is a possibility of blood or body fluid contact.

Based on observations, interview and record review the facility failed to identify and put into place interventions to prevent pressure sores in three high risk Patients (#7, #8, #9).

Findings included:
1. Record review of Patient #7's medical chart revealed the patient had been admitted to the facility on 4/22/10 for physical therapy, occupational therapy and skilled care.

- Record review of the History and Physical (H&P) dated 4/23/10 in part revealed the following information:
-She is a thin, frail, chronically ill appearing elderly (82) white female
-The patient fell with a resulting right hip fracture which was treated with Open Reduction Internal Fixation (ORIF) [open surgery is set bones with screws and/or plates].
-Nursing has noticed some bruising and possible beginning of a pressure sore on her buttocks.
-The patient has a sore on the top of her left foot.

Past medical history:
-Dementia with delusions
-hypertension
-anxiety
-Chronic Obstructive Pulmonary Disease
-Parkinson's Disease
-Osteoarthritis
-Osteoporosis

Physical exam:
-There is one small area just over the cecum (sic) [coccyx] which appears to be an abrasion, but not necessarily a pressure ulcer.
-She does have an ulcer noted to the top of the left foot which is chronic.

Plan:
-For the ulcer on the left foot we'll begin SkinTegrity gel (a gel used for the maintenance of a moist wound environment) dressings with gauze and overlying tape changing twice a day for one week then once daily.
-We'll watch the area on her bottom very closely. I think this is mainly a bruise, but she is very high risk for that to develop into an ulcer due to her very thin frame. We will make sure she is turned frequently and up out of bed as much as possible.

Record review of the Nursing Data Base dated 4/22/10 in part revealed the following information:
-Neurological - Symptoms
Weakness
Parkinson Disease (a progressive disease which results in impairment of speed and physical movement)
-Genitourinary - Symptoms
Nocturia (frequent urination at night)

-Musculoskeletal - Symptoms
Pain
Falls
Fracture/Right Hip repair
Back Pain/Right hip pain

-Skin - Symptoms
Bruising
Ulcer left foot (top)
Bruise on coccyx (tailbone)
Sutures right hip
Psychosocial - Comments
Stands - (Weight bearing as tolerated (WBAT) no ambulation

-Swing Bed (SB) Assessment Sheet dated 4/22/10
Skin
Broken areas
Location: Stage I coccyx, Stage 2-3 on top of left foot
Treatments: Frequent turning, exuderm (a medication used for minimally draining sores) to foot
Comments Stage 2-3 with yellow slough reddened area 2x3 centimeters (cm)

-Physical Functions
Limited assist (assist of 1) with bed mobility, transfer, locomotion, dressing, toileting, bathing, ADL and supervision with eating.

-Ambulation with a walker.

-Record review of the Skin Assessment: Illustrate skin, lesion, incision, amputations, etc. revealed in part the following information:

Abrasion on Left and Right Elbows
Reddened but no blisters on bilateral heels
Stage 2 2x3 cm with yellow exudates covered with exuderm
Bruising on right inner/outer thigh and at right pubis
Sutures from recent surgeries

-Record review of the patient Plan of Care in part revealed the following information:
- The Plan of Care was initiated on 4/25/10; three days after the patient was admitted to the facility.
- The Plan of Care included:
Impaired skin integrity r/t left foot ulcer bruise on coccyx
-No interventions were documented for pressure relieving devices, turning or repositioning although this patient was identified by nursing as having skin breakdown and being at high risk.
-No individualized goal was documented for this patient. The goal stated the client will maintain skin integrity.

- Observation on 5/17/10 at 1:45 p.m. revealed Registered Nurse (RN) C enlisted the aid of another staff member to reposition the patient. The patient attempted to assist but was unable to do more than grip the bed rail.

-During an interview on 5/17/10 at 2:00 p.m. Director of Nursing B stated there was no formalized tool to assess for risk of pressure sores. He/she stated each nurse made an assessment each shift and put into place any intervention needed to prevent pressure sores.

2. Record review of Patient #8's medical chart revealed the patient was admitted to the facility on 5/14/10 for pneumonia and vancomycin resistant enterococcus (VRE).

Record review of the H&P dated 5/14/10 in part revealed the following information:
- Past Medical history:
- Stroke
- Depression
- Recent compression fracture from a fall

Review of Systems:
- Rectal tube (a tube inserted into the rectum to collect feces)
Record review of the Nursing Data Base in part revealed the following information:
- Neurological - Symptoms:
- Weakness
- Pain

- Pulmonary - Symptoms:
-Dyspnea ( shortness of breath )(exertional)
-Dyspnea (at rest)
Pulmonary diagnosis:
-Pneumonia
Musculoskeletal - Symptoms:
-Falls
-Arthritis
-Compressed fracture of the back in April

Record review of the Plan of Care dated 5/14/10 in part revealed the following information:
- Fluid Volume Deficient and Activity Intolerance were identified in the Plan of Care.
- Potential for skin breakdown was not included in the Plan of Care although the patient was identified by the nursing staff as high risk for skin breakdown.


- Observation on 5/17/10 at 3:00 p.m. revealed Registered Nurse (RN) C and RN D repositioned the patient. RN D placed the patient's hand on the rail and the patient attempted to assist the two staff.

-During an interview on 5/17/10 at 3:10 p.m. RN D stated the patient would kind of wiggle to his/her back but was unable to turn.

3. Record review of Patient # 9's medical record revealed the patient had been admitted to the facility on 5/17/10 for dehydration, failure to thrive and mental status changes.

-No record review of the H&P as it had not been dictated at this time. -

Record review of the Nursing Data Base dated 5/17/10 (no time) in part revealed the following information:

-Neurological - Symptoms:
Weakness
Stroke 2007 and 2008 with affected area right side.
Subdural bleed (a bleed in the brain between two spaces) 2009

-Genitourinary - Symptoms:
Incontinence - foley

Musculoskeletal
-Psychosocial - Needs assistance with:
Mobility, Transfers, Hygiene, Dressing, Feeding

-Record review of the Nursing Care Flow Sheet in part revealed the following information:
Activity - Turns self

-Observation on 5/18/10 at 8:20 a.m. revealed the staff x 4 transferring the patient from his/her bed to a cart for an x ray. The patient was unable to assist with his/her transfer in any way.

3. Record review of Patient #13 medical chart revealed the patient was admitted to the facility on 3/26/10 for generalized weakness, shortness of breath, redness and inflammation and pain in the right lower extremity as well as some swelling and pretibial edema ( nonpitting [swelling which does not leave an indentation when depressed] swelling)of the right lower extremity and sudden onset of increased mental status changes.

-Record review of the patient's medical chart in the Nursing Data Base dated 3/26/ (no year) in part revealed the following information:
-Skin
Lesin (sic) under Right breast

-Record review of the Nursing Care Flow Sheets in part revealed the following information:
The staff documented under Turns the patient needed assist on 3/26/no year, 3/27/10, 3/28/year.
The staff documented under Turns the patient turned self on 3/29/no year, 3/30/no year and 3/31/no year.
The staff did not document the assistance needed for turning on 3/27/10 7a-7p, 3/29/no year 7a-7p, 3/30/no year 7p-7a, 3/31/no year 7p-7a
The staff documented on 3/28/no year under Turns prn or as need on 7a-7p.

-Record review of the Nursing Notes revealed the following information about the patient:
- On 3/27/10 the patient had difficulty in moving around
-Was assisted from bed to chair with maximum assist at 4:00 p.m. and sat in the chair until documentation revealed the patient was assisted back to bed at 9:30 p.m. with assist of two and a walker.
- On 3/28/no year revealed the patient:
-Was assisted to bed x 2 at 2:45 p.m. Heavy assist x 2. And remained in bed until
patient was taken to x ray at 9:00 a.m on 3/29/no year and then assisted back to bed and remained in bed until patient was assisted to chair with difficulty at 2:00 p.m.
-On 3/29/no year and remained in bed until 3:15 p.m. on 3/30/no year until
-On 3/31/no year at 12:00 p.m. the patient was assisted to a chair for lunch with assist of 2 and remained there until 9:30 p.m. when the patient was assisted to bed with a maximum assist of 2. Documentation revealed the patient stood and pivoted and could not follow instructions to move towards the center of the bed.
-On 3/31/no year the staff documented the patient had turned him/herself from back to right until
-6:00 a.m. when documentation shows the patient was turned "to back". Documentation revealed the patient could turn herself to her right side but can't get to back again without assist.

-Record review of the Nursing Care Flow Sheet on 4/3/10 7a-7p revealed the patient had a closed blackened area or right heel - unblanchable (skin that when pressed does not return from pale to red).

On 4/3/10 at 5:00 p.m. patient was sitting up in chair and was assisted back to bed at 8:30 p.m. with assist of 2.
On 4/4/10 7a-7p the documentation revealed the patient turned self and on 7p-7a the patient needed assist. No documentation on 7a-7p of assessment of heels, coccyx or spine. On 7p-7a documentation revealed red heels.
On 4/4/10 at 9:50 a.m. the patient was maximum assist to chair.
At 7:30 p.m. the patient was lying in bed.
On 4/5/no year there is no documentation of Turns by the 7a-7p shift and the 7p-7a shift documents self for turning.
On 4/5/no year there is no documentation for heels, coccyx and spine and the 7p-7a shift documented red right heel.
On 4/5/no year at 11:00 a.m. documentation revealed the patient had been up in chair this am.
On 4/5/no year at 11:30 p.m. documentation revealed the patient is assisted to bed by lifting to stand position and pivoting to bed.
On 4/6/no year documentation revealed the patient need assistance as needed with turns.
On 4/6/no year at 7:30 a.m. documentation in the Nursing Notes revealed the patient was in bed with the head of bed up for tray.
On 4/6/no year at 10:00 a.m. documentation revealed in chair patient.

-Record review of the Summary of Swing bed Therapies documented the patient had bruises on arm - (small).

-Record review of the Swingbed Discharge Summary with discharge date of ?/6/10 at 3:10 p.m. revealed the patient had no type of wound.

-Record review of the Plan of Care dated 3/31/10 revealed the staff identified and prioritized the following:
-Alteration in comfort: r/t generalized Discomfort Osteoarthritis (OA), Rheumatoid Arthritis (RA)
-Potential for Infection
-Altered Physical Mobility r/t discomfort
-Discharge Planning
No interventions were put in place for turning, pressure relieving device such as foot booties, air mattress etc.

-During an interview on 5/17/10 at 8:30 a.m. Licensed Practical Nurse (LPN) F stated the patient was confused, on bed rest and and needed maximum assist with Activities of Daily Living (ADL's) [grooming, eating, bathing, transfers, dressing and feeding]. The LPN stated the patient would be at high risk for impaired skin integrity.

-Record review of the facility policy provided by the DON titled Policy on Focus Charting dated June 20, 1994 in part revealed the following information:

Purpose: Nursing care at Samaritan Memorial Hospital will be documented by those members of the health care team that care for the clients. Documentation will, 1) reflect the nursing process through the use of assessment, planning, intervention, and evaluation, 2) reflect current nursing practice guidelines for the patient's condition.

Procedure:

10. Re-assessment of problems are completed at the beginning of each 12 hour shift and as determined by a change in the client's condition.

Based on observations, interview and record review the facility failed to identify/develop and/or update care plans addressing interventions, goals and timelines for three in-patients (Patient #7, #8, #9) and one closed record (Patient # 13) assessed as high risk for skin breakdown. The facility census was 15.

Findings included:

1. Record review of Patient #7's medical chart revealed the patient had been admitted to the facility on 4/22/10 for physical therapy, occupational therapy and skilled care.

- Record review of the History and Physical (H&P) dated 4/23/10 in part revealed the following information:
-She is a thin, frail, chronically ill appearing elderly (82) white female
-The patient fell with a resulting right hip fracture which was treated with Open Reduction Internal Fixation (ORIF) [open surgery is set bones with screws and/or plates].
-Nursing has noticed some bruising and possible beginning of a pressure sore on her buttocks.
-The patient has a sore on the top of her left foot.

Past medical history:
-Dementia with delusions
-hypertension
-anxiety
-Chronic Obstructive Pulmonary Disease
-Parkinson's Disease
-Osteoarthritis
-Osteoporosis

Physical exam:
-There is one small area just over the cecum (sic) [coccyx] which appears to be an abrasion, but not necessarily a pressure ulcer.
-She does have an ulcer noted to the top of the left foot which is chronic.

Plan:
-For the ulcer on the left foot we'll begin SkinTegrity gel (a gel used for the maintenance of a moist wound environment) dressings with gauze and overlying tape changing twice a day for one week then once daily.
-We'll watch the area on her bottom very closely. I think this is mainly a bruise, but she is very high risk for that to develop into an ulcer due to her very thin frame. We will make sure she is turned frequently and up out of bed as much as possible.

Record review of the Nursing Data Base dated 4/22/10 in part revealed the following information:
-Neurological - Symptoms
Weakness
Parkinson Disease (a progressive disease which results in impairment of speed and physical movement)
-Genitourinary - Symptoms
Nocturia (frequent urination at night)

-Musculoskeletal - Symptoms
Pain
Falls
Fracture/Right Hip repair
Back Pain/Right hip pain

-Skin - Symptoms
Bruising
Ulcer left foot (top)
Bruise on coccyx (tailbone)
Sutures right hip
Psychosocial - Comments
Stands - (Weight bearing as tolerated (WBAT) no ambulation

-Swing Bed (SB) Assessment Sheet dated 4/22/10
Skin
Broken areas
Location: Stage I coccyx, Stage 2-3 on top of left foot
Treatments: Frequent turning, exuderm (a medication used for minimally draining sores) to foot
Comments Stage 2-3 with yellow slough reddened area 2x3 centimeters (cm)

-Physical Functions
Limited assist (assist of 1) with bed mobility, transfer, locomotion, dressing, toileting, bathing, ADL and supervision with eating.

-Ambulation with a walker.

-Record review of the Skin Assessment: Illustrate skin, lesion, incision, amputations, etc. revealed in part the following information:

Abrasion on Left and Right Elbows
Reddened but no blisters on bilateral heels
Stage 2 2x3 cm with yellow exudates covered with exuderm
Bruising on right inner/outer thigh and at right pubis
Sutures from recent surgeries

-Record review of the patient Plan of Care in part revealed the following information:
- The Plan of Care was initiated on 4/25/10; three days after the patient was admitted to the facility.
- The Plan of Care included:
Impaired skin integrity r/t left foot ulcer bruise on coccyx
-No interventions were documented for pressure relieving devices, turning or repositioning although this patient was identified by nursing as having skin breakdown and being at high risk.
-No individualized goal was documented for this patient. The goal stated the client will maintain skin integrity.

- Observation on 5/17/10 at 1:45 p.m. revealed Registered Nurse (RN) C enlisted the aid of another staff member to reposition the patient. The patient attempted to assist but was unable to do more than grip the bed rail.

-During an interview on 5/17/10 at 2:00 p.m. Director of Nursing B stated there was no formalized tool to assess for risk of pressure sores. He/she stated each nurse made an assessment each shift and put into place any intervention needed to prevent pressure sores.

2. Record review of Patient #8's medical chart revealed the patient was admitted to the facility on 5/14/10 for pneumonia and vancomycin resistant enterococcus (VRE).

Record review of the H&P dated 5/14/10 in part revealed the following information:
- Past Medical history:
- Stroke
- Depression
- Recent compression fracture from a fall

Review of Systems:
- Rectal tube (a tube inserted into the rectum to collect feces)
Record review of the Nursing Data Base in part revealed the following information:
- Neurological - Symptoms:
- Weakness
- Pain

- Pulmonary - Symptoms:
-Dyspnea ( shortness of breath )(exertional)
-Dyspnea (at rest)
Pulmonary diagnosis:
-Pneumonia
Musculoskeletal - Symptoms:
-Falls
-Arthritis
-Compressed fracture of the back in April

Record review of the Plan of Care dated 5/14/10 in part revealed the following information:
- Fluid Volume Deficient and Activity Intolerance were identified in the Plan of Care.
- Potential for skin breakdown was not included in the Plan of Care although the patient was identified by the nursing staff as high risk for skin breakdown.


- Observation on 5/17/10 at 3:00 p.m. revealed Registered Nurse (RN) C and RN D repositioned the patient. RN D placed the patient's hand on the rail and the patient attempted to assist the two staff.

-During an interview on 5/17/10 at 3:10 p.m. RN D stated the patient would kind of wiggle to his/her back but was unable to turn.

3. Record review of Patient # 9's medical record revealed the patient had been admitted to the facility on 5/17/10 for dehydration, failure to thrive and mental status changes.

-No record review of the H&P as it had not been dictated at this time. -

Record review of the Nursing Data Base dated 5/17/10 (no time) in part revealed the following information:

-Neurological - Symptoms:
Weakness
Stroke 2007 and 2008 with affected area right side.
Subdural bleed (a bleed in the brain between two spaces) 2009

-Genitourinary - Symptoms:
Incontinence - foley

Musculoskeletal
-Psychosocial - Needs assistance with:
Mobility, Transfers, Hygiene, Dressing, Feeding

-Record review of the Nursing Care Flow Sheet in part revealed the following information:
Activity - Turns self

-Observation on 5/18/10 at 8:20 a.m. revealed the staff x 4 transferring the patient from his/her bed to a cart for an x ray. The patient was unable to assist with his/her transfer in any way.

3. Record review of Patient #13 medical chart revealed the patient was admitted to the facility on 3/26/10 for generalized weakness, shortness of breath, redness and inflammation and pain in the right lower extremity as well as some swelling and pretibial edema ( nonpitting [swelling which does not leave an indentation when depressed] swelling)of the right lower extremity and sudden onset of increased mental status changes.

-Record review of the patient's medical chart in the Nursing Data Base dated 3/26/ (no year) in part revealed the following information:
-Skin
Lesin (sic) under Right breast

-Record review of the Nursing Care Flow Sheets in part revealed the following information:
The staff documented under Turns the patient needed assist on 3/26/no year, 3/27/10, 3/28/year.
The staff documented under Turns the patient turned self on 3/29/no year, 3/30/no year and 3/31/no year.
The staff did not document the assistance needed for turning on 3/27/10 7a-7p, 3/29/no year 7a-7p, 3/30/no year 7p-7a, 3/31/no year 7p-7a
The staff documented on 3/28/no year under Turns prn or as need on 7a-7p.

-Record review of the Nursing Notes revealed the following information about the patient:
- On 3/27/10 the patient had difficulty in moving around
-Was assisted from bed to chair with maximum assist at 4:00 p.m. and sat in the chair until documentation revealed the patient was assisted back to bed at 9:30 p.m. with assist of two and a walker.
- On 3/28/no year revealed the patient:
-Was assisted to bed x 2 at 2:45 p.m. Heavy assist x 2. And remained in bed until
patient was taken to x ray at 9:00 a.m on 3/29/no year and then assisted back to bed and remained in bed until patient was assisted to chair with difficulty at 2:00 p.m.
-On 3/29/no year and remained in bed until 3:15 p.m. on 3/30/no year until
-On 3/31/no year at 12:00 p.m. the patient was assisted to a chair for lunch with assist of 2 and remained there until 9:30 p.m. when the patient was assisted to bed with a maximum assist of 2. Documentation revealed the patient stood and pivoted and could not follow instructions to move towards the center of the bed.
-On 3/31/no year the staff documented the patient had turned him/herself from back to right until
-6:00 a.m. when documentation shows the patient was turned "to back". Documentation revealed the patient could turn herself to her right side but can't get to back again without assist.

-Record review of the Nursing Care Flow Sheet on 4/3/10 7a-7p revealed the patient had a closed blackened area or right heel - unblanchable (skin that when pressed does not return from pale to red).

On 4/3/10 at 5:00 p.m. patient was sitting up in chair and was assisted back to bed at 8:30 p.m. with assist of 2.
On 4/4/10 7a-7p the documentation revealed the patient turned self and on 7p-7a the patient needed assist. No documentation on 7a-7p of assessment of heels, coccyx or spine. On 7p-7a documentation revealed red heels.
On 4/4/10 at 9:50 a.m. the patient was maximum assist to chair.
At 7:30 p.m. the patient was lying in bed.
On 4/5/no year there is no documentation of Turns by the 7a-7p shift and the 7p-7a shift documents self for turning.
On 4/5/no year there is no documentation for heels, coccyx and spine and the 7p-7a shift documented red right heel.
On 4/5/no year at 11:00 a.m. documentation revealed the patient had been up in chair this am.
On 4/5/no year at 11:30 p.m. documentation revealed the patient is assisted to bed by lifting to stand position and pivoting to bed.
On 4/6/no year documentation revealed the patient need assistance as needed with turns.
On 4/6/no year at 7:30 a.m. documentation in the Nursing Notes revealed the patient was in bed with the head of bed up for tray.
On 4/6/no year at 10:00 a.m. documentation revealed in chair patient.

-Record review of the Summary of Swing bed Therapies documented the patient had bruises on arm - (small).

-Record review of the Swingbed Discharge Summary with discharge date of ?/6/10 at 3:10 p.m. revealed the patient had no type of wound.

-Record review of the Plan of Care dated 3/31/10 revealed the staff identified and prioritized the following:
-Alteration in comfort: r/t generalized Discomfort Osteoarthritis (OA), Rheumatoid Arthritis (RA)
-Potential for Infection
-Altered Physical Mobility r/t discomfort
-Discharge Planning
No interventions were put in place for turning, pressure relieving device such as foot booties, air mattress etc.

-During an interview on 5/17/10 at 8:30 a.m. Licensed Practical Nurse (LPN) F stated the patient was confused, on bed rest and and needed maximum assist with Activities of Daily Living (ADL's) [grooming, eating, bathing, transfers, dressing and feeding]. The LPN stated the patient would be at high risk for impaired skin integrity.

-Record review of the facility policy provided by the DON titled Policy on Focus Charting dated June 20, 1994 in part revealed the following information:

Purpose: Nursing care at Samaritan Memorial Hospital will be documented by those members of the health care team that care for the clients. Documentation will, 1) reflect the nursing process through the use of assessment, planning, intervention, and evaluation, 2) reflect current nursing practice guidelines for the patient's condition.

Procedure:

4. Following the assessment, the registered nurse will identify and prioritize a problem list for the patient's hospital stay, whether it is for inpatient or outpatient. The problem list will identify the focus of nursing care for the patient; the most important being # 1, the second most important being #2, and so on.
8. Additional problems may be added to the problem list as the client's condition changes. Priorities may also change during the clients hospital stay. (How can we re-prioritize?)

10. Re-assessment of problems are completed at the beginning of each 12 hour shift and as determined by a change in the client's condition.

13. The patient problem list is reviewed at least once every 12 hours to determine if
the list remains reflective of the patient's current condition.

Based on observation, interview and record review, the facility failed to ensure patient confidentiality by displaying the patient name, medical record, and date of birth are placed on the outside of exam room doors for three (Patient #17, Patient #18, and Patient #19) of three patients observed in the Emergency Department (ED) and two of three Patients #7 and #8 observed on the unit when staff did not close the privacy curtains and/or window curtains. The facility census was 15 patients, ten Swing status and five acute.

Findings included:

Record review of Policy titled: Confidentiality, effective Date 04/14/03, without a revision date showed the following :

-A patient's confidential health information is protected, including demographic information that identifies the individual (Section 2.0 (i)).
-All members of the hospital are responsible for protecting confidentiality while carrying out their responsibilities (Section 3.1).

Record review of Patient Rights showed the patient has the right to every consideration of privacy and confidentiality concerning his/her own medical care program, including treatment (bullet five).

1. Observation on 5/17/10 at 1:36 P.M. the ED revealed patient identification stickers are placed on the outside of exam room doors. The patient name, medical record, primary physician, and date of birth are visible to other patients and visitors walking by. This was observed on Exam Room 2 (Patient #17), Exam Room 3 (Patient #18), and ER 2 (Patient #19).

During an interview on 5/17/10 at 2:00 P.M., Staff L, Emergency Medical Technician (EMT) Paramedic said the patient identification stickers are placed on cards on the outside of patient rooms so supplies and charges can be tracked.


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Findings included:

2. Observation on 5/17/10 at 1:40 p.m. revealed Registered Nurse C removed the sheets and blankets and lifted the gown from Patient #7 to do a skin assessment of hip, back, legs and feet. The curtain to the first floor window was not closed. This window looked out onto a grassy area with potential for the patient to be exposed to others.

3. Observation on 5/17/10 at 3:00 p.m. revealed Registered Nurse C and Registered Nurse D removed the sheets and blankets and lifting the gown of Patient #8 to do a skin assessment of back, legs, feet and abdomen. The inner door of the room was closed but it contained a large uncovered piece of glass. The outer door which was solid was not closed thereby potentially exposing the patient to visitors. The curtain to the first floor window was not closed. A man on the outside of the facility walked by the window within 15 feet of the patient.

Record review of the facility policy on Patient Rights (no date) in part stated the following information:
-The patient has the right to every consideration of privacy and confidentiality ... Case discussion, consultation examination, and treatment are confidential, and should be conducted discreetly.

Record review of facility's policy titled Admission of Patient revised dated11/29/2000 in part revealed the following information:
Procedure
4. Provide privacy