HospitalInspections.org

Based on medical record review, policy review, and staff interview the facility staff failed to develop the patient plan of care based on physician orders post operatively and patient ability to transfer.

Findings were:

Review of medical record for patient #1 revealed the nursing plan of care for activity and weight bearing status did not match physician orders for the patient post surgery on 8/14/19.

Patient #1 had surgery for bilateral debridement of ulcers on bottom of feet for osteomyelitis performed on 8/14/19.

Patient had post-operative orders on 8/14/19 for activity as follows:
Activity-Out of bed with assistance; Up in chair
Weight Bearing Status-Non-Weight Bearing bilateral foot

Plan of Care: 8/14/19-8/16/19
Medical record review for the patient revealed the following deficiencies in care planning:
Ambulatory Aid: (None/Bedrest/Wheelchair)
Gait/Transferring: (Impaired-help walking/rising from chair/shuffles/grabs)
Fall Risk Score: 40
Low fall risk score of 25-44 on Morse fall scale.
Musculoskeletal: Activity/Level of Assistance Activity/Level of Assistance: bedrest; w/1 person assist.


Facility policy titled "Transfer Technique: Assisting Patients from Bed to Chair-CE" states in part;
ALERT
Use lifting and transfer devices when available.
Assess the patient's physiologic capacity to transfer.
Assess the patient for weakness, dizziness, or postural hypotension.
Assess the patient's level of endurance.
Assess the patient for specific risks of falling when transferred.
Determine the patient's previous mode of transfer (if applicable).
Determine the need for special transfer equipment. To reduce the risk of musculoskeletal injury, use a mechanical lift device to transfer the patient from the bed to a chair.
Explain the procedure to the patient and ensure that he or she agrees to treatment.
If patient is capable of normal weight-bearing and has upper body strength, assist him or her to a sitting position on the side of the bed.
MONITORING AND CARE
Ask if the patient experienced pain during the transfer.
Rationale: Evaluating the character and degree of pain and discomfort helps the nurse assess the need for additional pain control or for a change in the transfer technique.
Per the practitioner's order, have the patient who transfers to a chair attempt to bear weight with the caregiver at his or her side.
Assess, treat, and reassess pain.
DOCUMENTATION
Pertinent observations during the procedure: weakness, ability to follow directions, weight-bearing ability, balance, ability to pivot, number of persons needed to assist, and amount of assistance (muscle strength) required.
Unexpected outcomes and related interventions."

In an interview with staff #2 and #7 both acknowledged the nursing plan of care did not include the patient as being non-weight bearing and did not identify the use of a transfer aid until after the patient transfer incident on 8/16/19 when the patient was stood on her bandaged feet.