HospitalInspections.org

Based on review of hospital document and medical record, it was determined that the hospital failed to assure that the patient/patient's representative has the right to participate in the development and implementation of his/her plan of care, by failing to provide information regarding the patient's condition for 1 of 1 patient (Pt #2).

Findings include:

Review of hospital document titled Patient and Family Handbook revealed: "...The resident has the right to be fully informed in a language that he or she can understand, of his or her total health condition...."

Review of Pt #2's medical record revealed:

The Pt #2 was decisionally incapacitated and his mother had Medical Power of Attorney.

Pt #2 was admitted to the Long Term Acute Care Hospital (LTAC) on 7/9/10. A physician documented in the History and Physical on 7/12/10, that the patient had been transferred from an Acute Inpatient Hospital after being on the behavioral health unit for medication adjustment. The patient was found to have altered mental status and hypoxia with a 72% oxygen saturation on room air. He was evaluated in the Intensive Care Unit where he required intubation due to respiratory failure. The patient remained on ventilation and was diagnosed with pneumonia. Sputum cultures were positive for "MRSA" (Methicillin Resistant Staphylococcus aureus) and Klebsiella pneumoniae. He was placed on antibiotics. At the time of his transfer to the LTAC, he was no longer on antibiotics since the infection was colonized. He continued to be hypoxic and had a tracheostomy and was ventilator dependent. He no longer had a fever. He had a "PEG" (Percutaneous Endoscopic Gastrostomy) feeding tube in place. Review of the physician's assessment at the time of admission revealed: "...admitted...for trach management and ventilator-assisted respiratory failure...Acute mental status...Aspiration pneumonia with colonization of methicillin-resistant Staphylococcus aureus and Klebsiella...Schizophrenia...Bilateral lower extremity edema...Stage I-II right heel decubitus, continue wound care...Dyslipidemia...Gastrointestinal and deep venous thrombosis prophylaxis...Diabetes mellitus type 2...Hypertension...Anxiety...History of tobacco abuse...Vitamin D deficiency...Protein-calorie malnutrition...Fluid overload...."

Review of physician progress notes revealed the following:

7/10/10 at 1850: "...IPC (Inpatient Primary Care)...Asp (aspiration) pneumonia-colonization MRSA/Klebsiella...."

7/12/10: "...Pulmonary note...(no) Abx (Antibiotics)...completed Abx for pneumonia prior to admission."

7/13/10 at 0950: "...IPC...Asp pneumonia MRSA...Heavy Growth...Abx regime done in Hosp...Vanco (Vancomycin) ID (Infectious Disease) C/S (Culture & Sensitivity)...."

7/14/10 at 0900: "...VDRF (Ventilator Dependent Respiratory Failure)/Asp pneumonia-Heavy Growth MRSA sputum...Vanco & Zosyn started. ID c/s...."
7/14/10: "...Pulmonary note...Sputum MRSA--Heavy growth...? colonized...Pt started on Vanco 7/13...Blood cult (culture) & Urine Cult of 7/13...pending...."

7/14/10: "...ID Consult...H/O (History of) Recurrent Resp failure...MRSA/Klebsiella...Completed 2 weeks of Rx (medication) at hospital...Cover for MRSA/Klebsiella again...."

7/16/10: "...Wound Care...Pneumonia/sepsis...."

7/16/10 4:30PM: "...Renal...Staph bacteremia...."

7/16/10: "...ID...Bacteremia staph sp ? MRSA...if recent MRSA - pneumonia concern would be para pneumoniae (complicated)-effusions>empyema...If MRSA identified--CT (Computed tomography) of chest...Repeat BC (Blood Culture)...Vanco...keep higher side/15-20...IV#2...Vanco...Zosyn...."

7/20/10: "...ID...MRSA Bacteremia/Sepsis...R/O (Rule Out) empyema...CT Chest/Abdomen...."

Review of laboratory reports revealed the following:

"...Collected date...7/10/10...Reported date.. 7/13/10...Culture, Sputum...Staphylococcus aureus...MRSA...heavy growth...Susceptible...Vancomycin...."

"...Collected date...7/13/14...Reported date...7/14/10...Culture, Blood...R (right) Arm...No growth to date...L (left) Arm...No growth to date...."

"...Collected date...7/13/10...Reported date...7/14/10...Culture, Blood R Arm...No growth to date...L Arm...Gram positive cocci-seen in Gram Stain only...."

"...Collected date...7/16/10...Reported date...7/22/10...Culture, Blood...Specimen Source...Peripheral...No Growth...."

"...Collected date...7/20/2010...Reported date...7/26/10...Culture, Blood...No Growth...."

Case Management notes indicate that an RN Case Manager met with the patient's family members on 7/12/10, 7/20/10, 7/22 and 7/23/10. Case Management notes do not contain information regarding informing the family specifically of the presence of sepsis syndrome. Case Management notes dated 7/22/10, contain information that the family was aware of "...CT scan results showing masses in his chest...."

A physician noted on 7/21/10 at 1540 that s/he reviewed the "chart/case extensively" with the nurse practitioner and the family, including the lab reports and medication administration. S/he noted that the patient had "staph sepsis" at that time.

Review of the physician's Discharge Summary dictated 8/10/10 after the patient's death on 7/24/10, revealed: "...Discharge Diagnosis and Reason for Death: Multiorgan failure...Comorbidities/Medical History...Sepsis syndrome...The patient had come to this facility from...where he...began to experience hypoxia with respiratory failure secondary to possible aspiration pneumonia. His sputum was positive for MRSA and Klebsiella pneumoniae. The patient developed sepsis, required intubation, mechanical ventilation, and subsequent tracheostomy. The patient also developed significant metabolic encephalopathy and anasarca during that hospitalization...."

Neither physician progress notes, nor Case Management notes contained documentation of information provided to the family regarding whether the patient had "sepsis syndrome" at the time of his admission to the LTAC or not. Physician progress notes and lab reports indicated that bacteremia was identified on 7/14/10. Subsequent lab reports indicated no bacterial growth from blood specimens collected on 7/16/10 & 7/20/10.

The medical record did not contain information that the patient was admitted to the facility with sepsis syndrome. The MRSA and Klebsiella had been found in his sputum at the previous hospital and he had been given antibiotics for 2 wks and the bacteria was thought to be colonized at the time of his transfer. He was not on antibiotics when he was first admitted to the LTAC hospital. However, lab results indicated that there was heavy growth from the sputum that was obtained on 7/10 and reported on 7/13. Initial results of the blood culture from a blood specimen drawn on 7/13 were negative and then later (with gram stain) reported as positive. Antibiotics were started 7/13/10.

Based on review of hospital policy/procedure, medical records, and interview, it was determined that the hospital failed to:

1. require that a registered nurse evaluate the condition of a patient prior to transport to another facility and upon the patient's return per hospital policy/procedure for 1 of 1 patient (Pt #1).

2. require documentation of patient's repositioning every 2 hours per hospital policy/procedure for 1 of 1 patient (Patient #3).


Findings include:

1. Review of the hospital policy/procedure titled Transport of a Patient revealed: "...To provide hospital staff with guidelines to follow when a patient/resident needs to be transferred to another health care facility for...outpatient diagnostic testing...Procedure:...3. The following forms are required to be completed when a transport is necessary: a. A Patient Transfer/Transport Consent Form...5. Prior to transport and upon the patient/residents return, a nurse will document the patient/resident's condition in the nursing notes...8. If a patient/resident requires professional staff to accompany during transport, document this information on the last line of the Patient Transfer/Transport Consent form...."

Review of patient #1's medical record revealed a Patient Transfer/Transport Consent form dated 1/18/11 and timed 1000. The top half of the form was completed and contained information that the patient was being transported to a nearby hospital for an "MRI of head" (Magnetic Resonance Imagery). The bottom half of the form titled Certification of Explanation of Risk/Benefit of Transfer/Transport, is blank. This portion of the form contained a space for a physician or RN to complete by marking a box. The line indicated for the RN to mark contained the following: "...Based on my examination of the patient and communication with the physician, and the information available to me at the time of the transfer, I certify that the risks of transfer are outweighed by the benefits reasonably anticipated from proper care/services at the receiving facility. I have explained this to the patient/patient's representative...."

A section titled Certification of Condition contained three statements. A physician or RN was to mark one of the statements, indicating the patient's condition at the time of "transfer/transport:...The patient is in stable condition, there is no reasonable likelihood of deterioration from or during transfer/transport...The patient may be at risk for deterioration from or during transport, but the benefits outweigh the risks...The patient's condition cannot be stabilized within the capabilities of this hospital...." This section of the form was blank. The lines for the signature of the Physician or RN were blank.

The section to document Mode of Transport Arranged: "BCLS (Basic Cardiac Life Support)...ACLS (Advanced Cardiac Life Support)...Air...Private Vehicle...Other..." was blank.

The section to document: "...To be accompanied by: Transport Company Crew...Family/Friend...Other..." was blank.

Review of Case Management/Discharge Planning notes from a Family Conference on 1/12/11 at 1530 revealed: "...Respiratory therapy update on current tx (treatment) on aerosol trach collar vent (ventilator) on stand by...F/U (Follow/Up) MRI of brain...will be placed on vent when she goes for MRI...."

Review of Case Management/Discharge Planning notes on 1/17/11 at 1045 revealed: "...Vent weaning...1/12 ATC (aerosol trach collar) entire day...."

Review of the nursing notes on 1/18/11 revealed: "...1000 Pt sent by ambulence (sic) to...for MRI of head. VSS...1115 Pt back from...." The nursing notes did not contain documentation of the patient's condition before and after transport as required per procedure. The nurse did not complete the required documentation of the patient's condition, the mode of transport, or any required professional to accompany the patient during transport on the Transfer/Transport Consent form prior to transport. Documentation did not include whether the patient was placed on a ventilator for transport.

The Director of Nursing confirmed the incomplete transport documentation during an interview conducted on 02/17/11.

2. Review of the facility's policy and procedure titled "Lippincott Clinical Procedures" Policy #ADM 12 requires: "...The hospital...adopts...Lippincott...clinical procedures..clinical staff...."

Review of the Lippincott Manual of Nursing Practice, 8 th Edition 2006, page 187, revealed: "...Prevent pressure ulcer...Provide meticulous care and positioning...reposition every 2 hours...use alternating-pressure mattress or air-fluid bed...."

Review of the facility's policy and procedure titled "Turn Program Policy," Policy # CSM 138 revealed: "...Patients with low Braden Scores...limited ability to reposition...placed on Turning Program...."

Review of the patient's post flap orders (Patient #3) dated 07/13/10 at 1030 hours revealed: "...Turn left to right or back to opposite side every 2-4 hours...."

The Daily Nursing Record has a total of 8 pages. Page 4, line 12 contains the word "Turns" containing a key as follows: R-right, L-left, B-back, and I-independent. Included in the line is a total of 24 small columns indicating the hours in the day 00, 01, 02, through 23. Staff is to document (R, L, B, or I) position of the patient in the time column corresponding with the time the patient is turned.

Review of the patient's Daily Nursing Record dated 07/13/10 through 07/16/10, page 4, revealed documentation across all hours "Clinitron Bed refuses turning." The Nurses Progress Notes at 2000 hours revealed the patient was refusing to be turned, and would like to wait to be turned, "...requested for R (right) shoulder Lidocaine & Bacitracin to JP (Jackson-Pratt) sites to wait until wound care comes tomorrow so...only has to move once...."

Review of the patient's Daily Nursing Record dated 07/14/10 at 0000 hours page 4, revealed documentation across all hours "Clinitron Bed refuses turning." The Nurses Progress Notes at 2015 hours revealed: "...Clinitron bed, refuses to turn to do assessment...I am not moving more than once so they will just have to do it in the morning...."

Review of the patient's Daily Nursing Record dated 07/15/10 at 0000 hours page 4, revealed documentation across all hours "Clinitron Bed refuses turning." The Nurses Progress Notes at 0015 hours revealed: "...Pt (patient) on Clinitron bed, refuses repositioning...."

Review of the patient's Daily Nursing Record dated 07/16/10 at 0000 hours page 4, revealed documentation across all hours "Clinitron Bed refuses turning." The Nurses Progress Notes at 2200 hours revealed: "...Pt refused to be turned, stated they did my wound and turned me. Explained to pt that I needed to see his buttocks and back, pt stated not now...."

Review of the patient's Daily Nursing Record dated 07/17/10 through 09/02/10 page 4, revealed documentation the patient is now being turned at least every 2 hours (equal to 12 per 24 hours), except for the following dates:
07/26/10, it was documented the patient was turned 9 times.
07/27/10, it was documented the patient was turned 10 times, patient transported to another facility for thoracentesis procedure.
07/28/10, it was documented the patient was turned 11 times, patient transported to another facility for thoracentesis procedure.
08/06/10, it was documented the patient was turned 11 times.
08/10/10, it was documented the patient was turned 11 times.
08/12/10, it was documented the patient was turned 8 times, there was no documented turning from 0000 hours to 0700.
08/19/10, it was documented the patient was turned 10 times, patient transported to another facility for "CT" (computed tomography) of head.
08/21/10, it was documented the patient was turned 11 times, there was documentation "see turn sheet."
08/27/10, it was documented the patient was turned 9 times, patient to wound clinic.

Patient #3's Daily Nursing Records dated 07/12/10 through 09/03/10 revealed the patient's repositioning was not documented every two hours in 10 of the 52 days of hospitalization as required per policy.

RN #35 confirmed the following during an interview conducted on 02/17/11, that she remembered patient #3 had a lot of back pain and did not like to be turned. The patient was heavy and required 2-3 people to help turn.

RN #5 also confirmed the patient #3's spouse was concerned about the patient getting turned and a piece of paper was hung on the patient's wall to remind staff to frequently turn the patient. The RN remembers that the "turn schedule" on the wall had a key similar to the Daily Nursing Record with L, R, and B. The RN confirmed the nursing staff no longer uses the "turn schedule."

LPN #33 confirmed the following during an interview conducted on 02/17/11, patient #3 did not like to be turned, however, the patient did better with turning when the patient's spouse was at the bedside. The LPN "vaguely" remembers the "turn schedule" and was "unsure what it looked like."

The Wound Care Nurse #22 confirmed during an interview conducted on 02/17/11, remembers patient #3 refusing to be turned but does not recall a specific "turn schedule." Nurse #22 also confirmed the facility has added the "three P's" (pain, potty, position) to the Intake & Output sheet placed in the patient rooms to remind staff about positioning.

The Director of Nursing (DON) confirmed during an interview conducted on 02/18/11, that s/he had created the additional "turn sheet" (after talking with the patient's spouse) to remind staff to encourage and turn the patient. The DON also confirmed the "turn sheet" was not a part of the patient's record and the facility was no longer using the sheet.

The DON confirmed during the interview the documentation regarding turning was inconsistent.

Based on review of medical records and interview, it was determined that the hospital failed to require that a medical record is established and maintained for 4 of 30 patients (Pt's #11, #25, #27, & #30).

Findings include:

On 2/16/11, a review of Pt #11's medical record revealed that it contained 5 graphic sheets, dated 1/30/11 through 2/13/11 from Pt #25's medical record.

Employee #45, a Charge Nurse, confirmed on 2/16/11, that Pt 11's medical record contained portions of Pt #25's medical record.

On 2/17/11, a review of Pt # 27's medical record revealed that it contained a Medication Administration Record from Pt #30's medical record.

Employee #4 confirmed on 2/17/11, that Pt #27's medical record contained portions of Pt # 30's medical record.