HospitalInspections.org

Based on medical record review, staff interview and review of the facility policy the facility failed to ensure that there was an order for the use of a restraint for 1 out of 2 (patients #7 and #19) patients reviewed with restraints. The total sampled was 20 patients. The total facility census was 200 patients.

Findings include:;

During review of the medical record documentation of patient #7 it was noted that on 02/20/10 and 02/21/10, the patient was noted to have hand mitts on. On 02/20/10 the nursing notes state that the patient's left hand was in a mitt. There was no written order for the use of the restraint, no reason noted for the use of the restraint, no evidence that any less restrictive measures had been attempted and no monitoring documentation during the period that the mitt was on. On 02/21/10, the nursing notes state that the patient was in bilateral mitts. There was no physician order documented for the use of the bilateral mitts, no reason for the use of the mitts, no evidence that any less restrictive measures were attempted and no monitoring documentation during the period that the mitts were on or when they were removed.

At approximately 9:00 am on Thursday, March 18, 2009, Staff O reviewed the electronic portion of the patient's medical record for evidence of restraint monitoring. Staff O concurred that there was no evidence of monitoring or of documentation in regard to use of less restrictive measures.

Review of the facility policy ( Regional Policy HP004) revealed that the use of mitts is not considered a restraint unless it is used in conjunction with a wrist restraint, are tied too tightly or the mitts are too bulky. There was no factual description as to what "too bulky" constituted or what was tied too tightly meant.

At approximately 2:15 PM on Thursday, 03/18/10, Staff T stated that the mitts had been shown to a person from the Joint Commission Resources about a year ago and that they had approved the mitts as a non-restraint.

Based on medical record review, restraint policy review and staff interview 1 (patient #19) of 20 sampled patients patients reviewed did not have evidence that soft wrist restraints for Patient #19 were released at the earliest possible time.

Findings include:

Per review of the hospital's restraint policy HP004 on 03/18/10 at 9:30 AM, when a physical restraint is used it must be released at the earliest possible time. Per Patient #19's medical record review on 03/18/10, a nurses note dated 03/10/10 at 11:00 PM described combative behavior and confusion displayed by Patient #19 who had been admitted to the hospital on 03/09/10 with diagnoses including hyperkalemia, diarrhea, clostridium difficile and change in mental status. This 90 year old was placed in bilateral soft wrist restraints from 11:00 PM on 03/10/10 through 9:10 AM on 03/11/10. Nurses notes were written at 12:10 AM on 03/11/10 which described the patient's behavior as "resting, confused and yelling out at times." The next nurses note was written at 8:00 AM when the following was documented: "Patient is alert and oriented now and responsive now. Patient denied any pain. Soft wrist restraints remain on now. Breakfast tray ordered. Glucoscan 224. Patient seeing bugs on her blankets that are not there." At 9:10 AM, a nurses note documented the wrist restraints were off and the breakfast tray had been placed in front of the patient.

Per review of the electronic medical record on 03/18/10 at 8:50 AM, documentation relating to the patient's presentation from 3:00 AM-7:00 AM on 03/11/10 described Patient #19's behavior as "Confused/verbally abusive." Per interview with Staff C on 03/18/10 at 9:18 AM, Patient #19's bilateral soft wrist restraints should have been removed at 3:00 AM on 03/11/10 due to a lack of documented behavior which justified the continued use.

Based on medical record review, observation and staff interviews, 3 of 3 patients (patients
#10, #18 and #19) reviewed with skin breakdown did not have documented evidence of initial and ongoing evaluation of each patient's needs relating to prevention of, monitoring of and treatment of the skin of . The total patient sample included 20.

Findings include:

A review of Patient #10's medical record on 03/16/10 revealed this 82 year old was admitted to the hospital on 03/08/10 with acute bronchospasm, acute hypokalemia, coagulopathy secondary to warfarin, history of shortness of breath, hypertension, coronary artery disease, dementia, left hemiparesis and chronic obstructive pulmonary disease. On the initial nursing assessment dated 03/08/10, the skin risk assessment revealed a score of 13 which placed Patient 10 in the moderate risk for skin breakdown. This same assessment documented a stage 2-3 pressure area the size of a quarter on the left buttock. No further description or measurement was documented. This was verified by Staff C on 03/16/10 at 2:15 PM. Per directive on the multi-paged daily nursing assessment, a skin risk assessment is to be documented daily if the patient's score is 18 or less or if the patient is admitted with skin breakdown. No skin risk assessment was documented on 03/10/10, 03/11/10, 03/14/10 or 03/16/10. The flow sheet also directs nursing staff to initiate the PUP (pressure ulcer prevention ) protocol when the skin risk assessment is 18 or less. This PUP protocol includes using a Sof Care Seat cushion for the chair, turn every 1.5-2 hours using 30 degree side-lying position, placing an overlay mattress/specialty bed, skin protectant of incontinent and consider pressure reducing boots, friction reducing ankle pad or elevate heels off bed with pillow under legs.

A review of Patient #10's medical record revealed a skin risk assessment completed on 03/09/10 with a score of 13 (moderate risk). The first documentation that the PUP protocol was implemented was on 03/11/10 on the 7:00 AM-3:00 PM shift when an air mattress was applied to Patient #10's bed. Bilateral heel protectors were documented on 03/15/10. The use of barrier cream and a dressing was documented on 03/10/10 and 03/11/10 only. At no time was a measurement or other description of the pressure ulcer documented by nursing.

Per interviews on 03/17/10 at 12:15 PM with Staff C and Staff J, there should be an initial measurement and description of a wound at admission and when a dressing change is completed or at least every week. The area of the skin breakdown has been documented in the nurses notes as the left buttock, the right buttock and the coccyx. When observed on 03/16/10 at 12:05 PM, there were three areas blending into one bigger area on the left buttock. The skin breakdown was observed when Staff L cleaned the patient after urinary incontinence and changed the cushioned dressing which had been applied earlier that AM. Skin barrier above the open areas was observed. When Staff L was asked if she/he had measured the skin breakdown, the response was, "It's a stage 2." When asked if he/she had the tools to measure the wound, the response was "Yes". Staff C verified there were no descriptions or measurements in Patient 10's nursing notes after the initial assessment describing the wound as a stage 2-3 measuring the size of a quarter.

Per interview with Staff C and Staff I, there is a wound care nurse who sees all patients with skin breakdown and is available Monday-Friday. There are also skin champions on each wing who serve as a resource to the nurses for questions relating to skin breakdown. Per review of Patient #10's medical record, there was no documentation by either Staff S, the wound care nurse, or the skin champion on the unit. These findings were confirmed by Staff C on 03/16/10 in the afternoon.

Per review of Patient #18's medical record on 03/17/10, this patient was admitted to the hospital on 03/12/10 with diagnoses including gastro-intestinal bleed, small bowel obstruction, hypertension, congestive heart failure and hyperglycemia. In the patient's initial assessment dated 03/12/10 the skin risk assessment score was 12, placing the patient at high risk for skin breakdown. This assessment also included a note relating to the topical dressing which was in place on the left buttock and left shoulder with no description of either area of skin breakdown. On 03/13/10 the nursing flow sheet described the left flank and left buttock as having stage 2 pressure sores. As of 12:15 PM on 03/17/10, the medical record was silent to a description of Patient #18's skin breakdown. Without a description and measurement of the skin breakdown at the time of admission and during the hospitalization, the determination of whether the areas worsened, improved or stayed the same could not be made. This was verified by Staff C and Staff J at 12:15 PM on 03/17/10.

Per review of Patient #19's medical record on 03/17/10, this patient was admitted on 03/09/10 with diagnoses including hyperkalemia, diarrhea, clostridium difficile and change in mental status. The initial nursing assessment completed on 03/09/10 included a skin risk score of 14 placing the patient at moderate risk for skin breakdown and included " Has healing blister in the left inner thigh and buttock red and tender. Redness noted below both breasts and under the abdominal fold." There was no evidence of the PUP protocol being initiated during his/her hospitalization or prior to discharge on 03/15/10. No description or measurement of the healing blister or reddened buttock was found in the medical record. This area was referred to in the nurses note as being located on the buttocks, the sacrum and the coccyx during her/his hospitalization. At discharge on 03/15/10 the patient's "sacral wound" was being treated with a topical ointment. Therefore, it could not be determined if the patient's skin deteriorated, stayed the same or improved during the hospitalization. These findings were verified by Staff C on 03/17/10 in the afternoon.

Based on review of patient's medical records both current and discharged and interview with facility staff in regard to medical records and verbal orders, the facility failed to ensure that all verbal orders were signed, dated and timed and authenticated by the practitioner responsible for the care of the patient for 13 (patients #1-4, #8, #10-13, #15-16, and #18-19) current patient records and 7 (patients #5-7, #9, #14, #17, and #20) discharged patient records reviewed that had verbal orders.

Findings include:

During review of 13 (patients #1-4, #8, #10-13, #15-16, and #18-19) current patient records and 7 (patients #5-7, #9, #14, #17, and #20) discharged patient records revealed that verbal orders more than 48 hours old were not being signed, dated, timed or authenticated by any practitioner.

Interview with Staff C on Wednesday afternoon revealed that the facility's policy in regard to verbal order signing was that once the order was more than 48 hours old it was not to be signed as it was then past the time specified in the facility policy for signing verbal orders. Staff C further stated that Medical Records no longer flags the unsigned verbal orders and they are no longer counted as a delinquency for the physician. Staff C stated that the facility is in the process of moving the physicians' away from using any verbal orders except in the case of an emergency.

Staff C stated that the nurse's on the units are currently flagging verbal orders in hope that when the patients' physicians are on the unit they will sign the flagged verbal orders. Staff C stated that after the 48 hours the nursing staff no longer attempt to have the physicians sign the order. Staff G was on the phone with Staff C and concurred that this was their current practice and policy.

Based on review of medical records and interview of facility staff, the facility failed to ensure that the discharge plan for 2 ( Patients #7 and #13) out of 20 patients reviewed, included all the patient/family discharge needs.

Findings include:

During review of the medical record documentation for Patient #7, it was noted that the patient was receiving insulin injections and was on a sliding scale for dosage according to the glucose reading. The documentation revealed that prior to this hospitalization the patient had been on oral hypoglycemics and was not receiving insulin. The medical record documentation revealed that the patient had many comorbidities along with the diabetes and was not mentally capable of understanding or following instructions. The medical record documentation revealed that the patient's spouse was present at the bedside on many occasions and was involved in the discharge planning process for the patient. The discharge plan was for the patient to return home with care being given by the spouse and a home health agency. There was no documented evidence that there was any attempt to train the spouse or any other family member in the use of insulin administration. The discharge plan revealed that the same home health agency that the patient used previously would be seeing the patient upon discharge with the addition of a few new services (social work and home health aide). There was no documented evidence that the home health agency was made aware of the new order for insulin administration.

On Tuesday afternoon, 03/16/10, Staff C was asked to review the medical record to assist in finding any documentation in regard to diabetic teaching or training in regard to insulin administration. Staff C was asked if perhaps the training/teaching was in the electronic medical record but Staff C stated that the floor nurses that did any teaching would chart in the paper chart as would the Diabetic Educator. After reviewing the medical record, Staff C stated that there was no documented evidence of any training/teaching in the patient's medical record.

Patient #13 was to be discharged on 03/16/10 on an 1800 calorie, 2 gram sodium diet. During the patient interview, patient #13 stated that they were not aware of the 1800 calories but did know they were to limit their salt intake. Review of the patient's discharge information and nursing notes for the day of discharge revealed that there had not been any teaching/training done in regard to the 1800 calorie diet. This was confirmed by Staff I on Thursday, 03/18/10 at 2:23 PM.