HospitalInspections.org

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Based on a review of clinical records, review of facility policies, and interviews, the facility failed to ensure that nursing assessments were completed in accordance with facility policies for two of four patients, Patients #113 and #117, who required monitoring for alcohol withdrawal and/or for one of two patients, Patients #109, who entered the facility with compromised skin integrity, and/or failed to ensure that the physician/mid-level provider was notified in a timely manner and/or that treatment orders were obtained when one of two patients, Patient #116, entered the facility with compromised skin integrity. The findings include:


a. Patient #113 was admitted to the Emergency Department (ED) on 1/29/12 with diagnoses that included Alcohol Intoxication. Physician orders directed the patient to be monitored via the Clinical Institute Withdrawal Assessment (CIWA) protocol. Review of the clinical record with facility staff on 1/30/12 identified that Patient #113 was assessed via the CIWA scale on 1/29/12 at 11:37 PM with a resulting score of two (2). Patient #113 was not reassessed via the CIWA scale again until 6:55 AM on 1/30/12, more than seven hours later. Facility policy directed that patients who required monitoring via the CIWA protocol would be monitored using the determined components every two (2) hours for four (4) hours and then every four (4) hours thereafter.


b. Patient #117 was admitted to the ED on 1/26/12 with diagnoses that included Alcohol Intoxication. Physician orders directed the patient to be monitored via the Clinical Institute Withdrawal Assessment (CIWA) protocol and included specific direction for the administration of the medication, Ativan, for withdrawal symptoms. Review of the clinical record with facility staff on 1/30/12 identified that Patient #117 was assessed via the CIWA scale on 1/26/12 at 9:44 PM with a resulting score of ten (10). Ativan two milligrams (mg.) was administered in accordance with the protocol/physician orders. The record lacked documentation to reflect that Patient #117 was reassessed via the CIWA scale until 7:11 AM on 1/27/12. Review of the facility's CIWA protocol directed that patients on the protocol be reassessed within one half-hour after administration of Ativan.

c. Patient #109 was admitted to the facility on 1/27/12 with diagnoses that included a fall at home. The ED record identified that Patient #109 had sustained a left forearm skin tear that was bandaged upon admission to the ED. Review of the clinical record with facility staff dated 1/27/12 through 1/30/12 lacked documentation to reflect nursing assessments of Patient #109's skin tear that included measurements of the tear. The clinical record dated 1/30/12 at 9:00 AM described Patient #109's skin tear as 7.0 centimeters (cm.) by 0.25 cm. by 0.0 cm. Review of facility policy directed that all wounds be assessed at the time of admission and include wound measurements.

d. Patient #116 was admitted to the ED on 1/20/12 with diagnoses that include weakness/dizziness. Patient #116 was subsequently admitted to the hospital with a diagnosis of a Urinary Tract Infection (UTI). Review of the admission nursing assessment dated 1/20/12 at 9:38 PM identified that Patient #116 had a Stage III pressure ulcer on the coccyx that measured 1.5 centimeters (cm.) by 5.5 cm. by 0.3 cm., was irregularly shaped with a small amount of serosanguineous drainage, and described the wound bed as pink/red with yellow slough. Review of the clinical record dated 1/20/12 through 1/25/12 with Nurse Manager #7 on 1/30/12 lacked documentation to reflect that the physician and/or mid-level practitioner was notified of Patient #116's pressure ulcer and/or that physician orders for treatment to the patient's pressure ulcer were obtained until 1/25/12 when a consult by the facility's Wound Care Nurse was provided.
Interview with the Wound Care Nurse on 1/30/12 at 2:00 PM identified that facility policy directed that the physician and/or hospitalist be notified when a patient is identified to have a pressure ulcer on admission and/or develops a pressure ulcer during the hospitalization.

e. The documentation further identified that due to lack of notification to the physician and/or midlevel practitioner, no specific treatment orders were obtained to address Patient #116's community acquired pressure ulcer. The record identified that nursing staff washed the pressure ulcer with soap and water at least daily, left the Stage III pressure ulcer open to air, and on at least one occasion, applied a barrier cream to the wound. Review of the consult dated 1/25/12 by the facility's Wound Care Nurse identified that Patient #116's wound was covered with one hundred percent non-viable tissue that was unstageable and now measured 3.0 cm. by 2.8 cm. by 0.1 cm. Interview with the Wound Care Nurse on 1/30/12 at 2:00 PM identified that "barrier cream (was) not best practice" and that the physician or the wound care practitioner should have been notified for guidance/orders. The Wound Care Nurse stated that it was difficult to assess whether Patient #116's pressure ulcer had decompensated since admission or that the area was initially staged incorrectly by the nursing staff. Facility policy directed that treatment for Stage II-IV would be carried out in accordance with physician orders. The policy directed that if treatment orders are delayed, the nurse may apply a clean dressing to cover/protect that wound until the provider orders are obtained.



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Based on a review of the clinical record, review of facility policies, and interviews, the facility failed to ensure that the Emergency Department (ED) physician accurately completed an assessment to include a community acquired Stage III pressure ulcer for one patient, Patient #116, who was examined in the ED prior to admission to the facility for a Urinary Tract Infection (UTI). The finding includes:


a. Patient #116 was admitted to the Emergency Department (ED) on 1/20/12 with diagnoses that include weakness/dizziness. Review of the Emergency Physician Record dated 1/20/12 at 7:45 PM identified that the physician completed a systems review that included a review of the patient's skin. The record lacked documentation to reflect that Patient #116 had any skin impairment issues and had no decubitus ulcers (pressure ulcers). Patient #116 was subsequently admitted to the hospital with a diagnosis of a Urinary Tract Infection (UTI). Review of the admission nursing assessment dated 1/20/12 at 9:38 PM, conducted after admission to the inpatient unit, identified that Patient #116 had a Stage III pressure ulcer on the coccyx that measured 1.5 centimeters (cm.) by 5.5 cm. by 0.3 cm. that was irregularly shaped, with a small amount of serosanguineous drainage, and described the wound bed as pink/red with yellow slough. Interview with Patient #116 on 1/30/12 at 10:10 AM identified that he/she had acquired the pressure ulcer prior to admission and that he/she and his/her spouse had attempted to treat the pressure ulcer on their own at home. Review of facility policy directed that all wounds would be assessed at the time of admission. Interview with Nursing Manager #5 on 1/30/12 at 10:20 AM identified that the ED physician documentation was inaccurate based on Patient #116's admission to the facility with a community acquired pressure ulcer.

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Based on review of the clinical record, review of facility policies, and interviews, the facility failed to ensure that the Emergency Department (ED) provider utilized the Alcohol Intoxication panel that would have triggered monitoring for alcohol withdrawal symptoms for one of three patients, Patient #112, who sought treatment in the ED for alcohol intoxication. The findings include:

a. Patient #112 was admitted to the Emergency Department (ED) on 1/28/12 with diagnoses that included alcohol intoxication and a fall with a possible head injury. Physician orders directed a Computerized Tomography Scan (CT scan) of the cervical spine and a CT scan of the head without contrast with normal results reported. Review of the clinical record identified that Patient #112's breathalyzer results on admission were 0.111(Normal less than 0.8) and although the patient wanted to leave the ED, he/she was unable to be cleared to go home due to his/her intoxication and was subsequently was kept overnight in the ED. Review of the clinical record with facility staff lacked documentation to reflect that the ED provider initiated the facility's Alcohol Intoxication panel that included predetermined provider interventions. Interview with the ED Medical Director on 1/30/12 at 11:15 AM identified that facility policy directed that ED providers initiate the Alcohol Intoxication panel to ensure that patients admitted to the ED receive consistent treatment related to their diagnoses of alcohol abuse. The ED Medical Director stated that he/she had been monitoring use of the panel by ED providers as it was expected that the panel would be initiated on one hundred percent of patients admitted to the ED with alcohol intoxication.