HospitalInspections.org

Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:
1.) Failure of the RN to document routine vital signs for 2 (#1, #2) of 3 (#1, #2, #3) patients reviewed;
2.) Failure of the wound care nurse to assess a patient after consultation according to hospital policy for 2 (#1, #2) of 3 (#1, #2, #3) patients reviewed; and
3.) Failure of the RN to review and validate an initial admission assessment conducted by a LPN for 1 (#1) of 3 (#1, #2, #3) patients reviewed.

Findings:

1.) Failure of the RN to document routine vital signs for 2 (#1, #2) of 3 (#1, #2, #3) patients reviewed.

Patient #1
Review of Patient #1's medical record revealed Patient #1 was admitted on 03/01/2024 and discharged on 03/12/2024 at 2:30 p.m. Review of the physician order dated 03/01/2024 revealed vital signs- routine, unit specific. Review of Patient #1's documented vital signs revealed the last set of vital signs were documented on 03/12/2024 at 4:00 a.m.

In an interview on 03/13/2024 at 8:37 a.m. S3DMS stated the expectations of routine vital signs on the medical surgical unit are to be documented at 5:00 a.m. or 6:00 a.m., at 2:00 p.m., and at 8:00 p.m.

In an interview on 03/13/2024 at 9:49 a.m. S3DMS verified Patient #1 should have had vital signs documented at 2:00 p.m. S3DMS verified vital signs should have been documented prior to discharge.

Patient #2
Review of Patient #2's medical record revealed Patient #2 was admitted on 11/21/2023 and discharged on 01/11/2024 at 8:15 p.m. Review of the physician order dated 01/03/2024 revealed vital signs per routine. Review of Patient #2's documented vital signs revealed the last set of vital signs were documented on 01/11/2024 at 5:26 a.m.

In an interview on 03/12/2024 at 3:52 p.m. S3DMS verified Patient #2 should have had vital signs documented at least at 2:00 p.m. S3DMS stated staff should be documenting vital signs when a patient arrives (admission) and when a patient leaves (discharge) as well.

2.) Failure of the wound care nurse to assess a patient after consultation according to hospital policy for 2 (#1, #2) of 3 (#1, #2, #3) patients reviewed.

Review of the hospital's policy titled "Consults", revised 08/2023, revealed in part, all non-urgent physician consults should be completed by the consultant within 24 hours of notification. All patient consults within the ICU should be addressed by the consultant within 12 hours of notification. Further review revealed in part, the following consults may be also be generated by practitioner order or nursing assessment: dietitian; physical, occupational, or speech therapy; pharmacist; diabetes education; long term care; rehab; outpatient therapy; home health; social services; enterostomal therapy (wound care).

Patient #1
Review of Patient #1's medical record revealed Patient #1 was admitted on 03/01/2024 on the medical surgical unit. Further review revealed a wound care consult dated 03/02/2024 at 12:00 a.m. The wound care nurse's initial assessment was documented on 03/05/2024 at 3:16 p.m.

In an interview on 03/13/2024 at 8:59 a.m. S2DQ verified the wound care nurse's initial assessment should have been conducted within 24 hours of consult according to hospital policy.

Patient #2
Review of Patient #2's medical record revealed Patient #2 was admitted on 11/21/2023 on the ICU unit. Further review revealed a wound care consult dated 11/21/2023 at 7:00 a.m. The wound care nurse's initial assessment was documented on 11/24/2023 at 10:31 a.m.

In an interview on 03/12/2024 at 4:08 p.m. S2DQ verified the wound care nurse's initial assessment should have been conducted within 12 hours of consult according to hospital policy.

3.) Failure of the RN to review and validate an initial admission assessment conducted by a LPN for 1 (#1) of 3 (#1, #2, #3) patients reviewed.

Review of Patient #1's medical record revealed Patient #1 was admitted on 03/01/2024. Review of the initial admission assessment revealed the assessment was conducted on 03/01/2024 at 11:00 p.m. by S4LPN. Further review revealed no documentation of the assessment being reviewed and validated by a registered nurse.

In an interview on 03/13/2024 at 10:02 a.m. S1CNO stated a LPN can conduct an initial admission assessment but a RN must review and validate that assessment within 24 hours.

In an interview on 03/13/2024 at 10:14 a.m. S2DQ verified there was no documentation in Patient #1's medical record that a RN reviewed and validated the initial admission assessment.

Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed, and kept a current, and individualized nursing care plan for each patient that reflected the patient's goals and the nursing care expected to meet the patient's needs. This deficient practice was evidenced by the failure to create individualized care plans based on assessments for 2 (#2, #3) of 3 (#1, #2, #3) patients reviewed for completed and updated care plans.

Findings:

Review of the hospital's policy titled "Plan of Care - Nursing", revised 09/2023, revealed in part, A patient-centered care plan will be developed and initiated on all inpatients, to include age-specific elements as appropriate. A registered nurse will develop and initiate the plan of care. Further review revealed in part, Identify patient problems and determine if they are actual problems (acute and/or chronic) or potential problems. A patient who screens positive for fall risk, skin risk, or suicide risk are examples of patients who have a potential problem related to risks and would need preventive interventions included in the plan of care. Add the problems to the plan of care.

Patient #2
Review of Patient #2's medical record revealed Patient #2 was admitted on 11/21/2023. Review of the nursing assessment dated 11/22/2023 at 7:00 p.m. revealed in part, large discoloration to sacrum and buttocks with erythema around edges with darker non-blanchable areas. No skin breakdown noted. Area clean/dry and sacral dressings intact. Review of the enterostomal therapy nurse assessment dated 11/24/2023 at 10:31 a.m. revealed in part, Wound Location: Sacrum; Wound Type: Pressure; Wound Type Note: Patient found down at home. Wound present on admit; Pressure Wound Stage Note: Presenting DTI noted. Review of Patient #2's nursing care plan revealed wound care was initiated on 12/12/2023.

In an interview on 03/12/2024 at 1:22 p.m. S2DQ verified wound care should have been initiated within 24 hours of admission to Patient #2's care plan. S2DQ stated wound care was initiated on 12/12/2023.

Patient #3
Review of Patient #3's medical record revealed Patient #3 was admitted on 03/11/2024. Review of Patient #3's initial admission assessment revealed in part, partial amputation to left foot, top half amputated. Redressed foot with saline-soaked gauze, kerlix, and coban; clean, dry, intact. Review of Patient #3's nursing care plan failed to reveal wound care as a part of the plan of care.

In an interview on 03/13/2024 at 10:56 a.m. S2DQ verified Patient #3 was admitted with a wound, the admitting nurse documented the wound, and the nurse did not initiate wound care as part of Patient #3's plan of care.

Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors.

Findings:

Observation on 03/11/2024 at 4:01 p.m. - 4:24 p.m. of the medical surgical unit revealed peeling paint on the door frame of the bathroom in patient rooms 706 and 702.

In an interview during the observation, S2DQ verified the above stated findings.

Based on observation and interview, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented. This deficient practice was evidenced by the hospital failing to maintain a sanitary environment.

Findings:

Observation on 03/11/2024 at 10:09 a.m. - 10:38 a.m. of the ICU unit revealed 2 office style chairs with multiple tears in the seat covers in patient room 317 and 2 office style chairs with multiple tears in the seat covers at the desk in the hallway near patient room 3301. Due to the torn seat covers, all 4 chairs could not be disinfected.

In an interview during the observation, S5DICU verified the above stated findings.