HospitalInspections.org

Based on record review and interview the hospital failed to implement corrective action on the identified problem of inaccurate skin assessments performed and system-wide breakdown for implementation of wound care after the departure of the Certified Wound Care Nurse. Findings: (See findings at Tag A0395).

Review of the graph titled "Nosocomial Pressure Ulcers for the 3rd Quarter of 2009-3rd Quaarter of 2010 revealed a statistical value of <6 pressure ulcers aquired per 100 patient days. Further review revealed no documented evidence the data had been reviewed for trends.

In a face to face interview on 12/10/10 at 10:50am S21 RN Director of Nursing indicated she accepted responsibility for the lack of aggressive corrective action because she was trying to wait for the return of the Certified Wound Care Nurse who had gone out on sick leave at the beginning of summer. Further S21 confirmed the hospital had identified a problem with inconsistencies in the assessment of skin using the Braden Scale as well as in the Staging and care of the wounds.

Based on observation, record review and interview the hospital failed to meet the requirement for the Condition of Participation of Nursing Services as evidenced by:

1) Failing to ensure the RN supervised the accurate assessment and documentation of the patients' skin integrity and implementation of appropriate nursing preventative interventions for 9 of 9 patients with wounds or potential skin problems (#2, #3, #4, #5, #6, #7, #8, #9, #10 out of 10 sampled patients. This failure resulted in a 79 year old being admitted to the hospital with diagnoses of recurrent ischemic colitis, nausea, episodic vomiting and generalized weakness being assessed as a low to medium risk for developing a pressure ulcer even though the patient had predisposed medical conditions which included her skin as "thin and fragile"; nutrition altered due to nausea and vomiting; generalized weakness with limited mobility due to weakness, and dependence on others for assistance with all ADLs (Activities of Daily Living). Ten days after admit, the patient was assessed as having an unstagable pressure ulcer to the buttocks (#7). (See findings at Tag A0395);

2) Failing to ensure that nursing staff follow hospital policy and procedures for the nursing care of patients with wounds to include performing and documenting photographs of patients with wounds on admit, documentation of description of wounds to include staging and other required assessments, and failing to ensure that patients with wounds are care planned for treatment of wounds for 8 of 9 patients assessed with wounds (#2, #3, #4, #5, #6, #7, #8, #9) out of 10 sampled patients (See findings at Tag A0395, A0396)

20177

Based on observation, record review, and interview the hospital failed to ensure the RN supervised the assessment and documentation of the patients' skin integrity and/or wound care as evidenced by: 1) failure to ensure accurate skin assessments were performed for 9 of 9 patients with wounds and/or potential skin problems out of 10 sampled patients resulting in a chair-fast, immobile, Down's Syndrome patient with a Stage II pressure ulcer assessed as low risk on the Braden Scale and changed eight minutes later when re-assessed by another nurse to a high risk (#2); failure to ensure a patient who developed a pressure ulcer while in the hospital was accurately assessed and monitored (#3); for a 75 year old male admitted with respiratory failure as a result of rib fractures following a fall at home with a large bruise to the left side from the fall and multiple skin tags located on his back assessed as a low risk on the Braden Scale then changed to a low risk on the Braden Scale after developing a Stage 1 pressure ulcer to the buttocks and bilateral heels (#4); a 76 year old, 5 feet 2 inch, 134 pound female with a Stage 1 pressure ulcer to the right heel, an unstagable pressure ulcer to the left heel, an area of circular redness to the inner aspect of the left elbow and a bruise right at and above the left elbow, large area of shingles to the abdomen, right flank and back, bruising to the posterior thigh (no documented evidence of which thigh), and a Stage 2 pressure ulcer to the bilateral buttocks/coccyx assessed as being high risk on the Braden Scale changed to a low risk during a morning assessment and changed back to high risk at the evening assessment of the same day (#5); a weak and confused patient with excoriation to the left coccyx, incontinent and on bedrest assessed as medium risk on the Braden Scale and changed to low risk after developing a Stage II Decubitus Ulcer on his sacrum (#6); a 79 year old admitted with ecchymosis to the left arm and assessed as a medium risk on the Braden Scale changed to to a low risk and then back to a medium risk until the patient developed an unstagable pressure ulcer to the buttocks and was assessed as high risk (#7); a 53 year old male with a Stage IV diabetic foot ulcer assessed with a Braden Skin Score of 20 / no risk (#8); a bedridden patient with contractures assessed as being a high risk on the Braden scale then changed to a medium risk with four documented pressure ulcers in various stages and in documented poor nutritional health by the physician (#9); and a profoundly mentally retarded, bedridden patient assessed as being a high risk on the Braden Scale to a low risk with documentation of a healing pressure ulcer, cellulitis of the left leg, poor nutritional intake and who developed an abrasion to the shoulder after surgery (#10); 2) failure to follow hospital policy and procedure for performing and documenting photographs of patients with wounds on admit, when developed during hospitalization, and/or when the wound(s) were re-assessed for 8 of 9 patients assessed with wounds (#2, #3, #4, #5, #6, #7, #8, #9, #10) out of 10 sampled patients; and 3) failure to document in the medical record assessment of wounds which included staging, tunneling, undermining, wound bed description, surrounding tissue description, drainage, odor, color, and/or size (#2, #3, #4, #5, #6, #7, #8, #9) for 8 of 9 patients with wounds out of 10 sampled patients; Findings:

1) ensure accurate skin assessments were performed
Patient #2
Review of the History and Physical (H&P) for Patient #2 dated 12/02/10 revealed a 60 year old female was admitted to the hospital from a nursing home with the diagnoses of pyuria, bacteremia and a very high sodium level consistent with free water deficit. Further review of the medical history revealed #2 had Down's Syndrome, seizure disorder, diabetes mellitus, decubiti and previous amputations. Her level of consciousness and appetite had also decreased.

Review of the Adult Admit Assessment dated 12/02/10 revealed at the time of admit Patient #2 weighed 146 pounds. Review of the integumentary system section revealed her skin was pale, dry, flaky, thin and fragile with non-elastic turgor. Further review revealed #2 had a pressure ulcer to her left heel Stage II with eschar. She had no sensory perception impairment, occasional moist skin, activity confined to chair-fast with very limited mobility, adequate nutrition and a potential problem with friction/shear.

Review of the Braden Scale submitted as the one currently in use by the hospital and used to assess Patient #2 according to the information provided in the chart revealed the following: Sensory perception (3-slightly limited) according to the documentation in the medical record Patient #2 had a history of Down's Syndrome and when admitted was "moaning spontaneously"; Moisture (3-occasionally moist); Activity (1- bedfast as charted in the assessment notes along with severe weakness in all extremities); Mobility (1-completely immobile Patient #2 requires turning every two hours and requires total care for all ADLs (Activities of Daily Living); Nutrition (1 - medical diagnosis is free water deficit due to the critically high sodium level, risk for aspiration due to her decreased level of consciousness) and Friction and shear (1 - due to the patient being bedfast and already having documented skin breakdown). According to the Braden Scale Risk Level if other major risk factors are present (advanced age, fever, poor dietary intake of protein, diastolic pressure of < 60 or hemodynamic instability, advance to the next level of risk. After review of the point count from the assessment and the major risk factors, Patient #2 scored a 10 indicating a high risk and because she had fever and a low diastolic pressure this made her a very high risk for skin breakdown.

Review of the daily skin assessments utilizing the Braden scale were performed by the nursing staff for patient #2 on the following dates and with the following results:
12/02/10 at 1832 (6:32pm) Braden Scale score 16/Low
12/02/10 at 1940 (7:40pm) Braden Scale score 12/High
12/03/10 no documented evidence a skin assessment had been performed
12/04/10 at 0154 (1:54am) Braden Scale score 13/Medium
12/04/10 at 0730 (7:30am) Braden Scale score 12/High
12/05/10 at 0730 (7:30am) Braden Scale score 12/High
12/06/10 at 0800 (8:00am) Braden Scale score 12/High
12/06/10 at 2000 (8:00pm) Braden Scale score 12/High
12/07/10 at 0720 (7:20am) Braden Scale score 15/Low
12/04/10 at 0800 (8:00am) Braden Scale score 12/High
12/05/10 at Midnight Braden Scale score 9/Very High
12/05/10 at 1558 (3:58pm) Braden Scale score 12/High
12/06/10 at 0030 (12:30am) Braden Scale score 6/Very High
12/07/10 at 0800 (8:00am) Braden Scale score 8/Very High
12/07/10 at 2000 (8:00pm) Braden Scale score 10/High
12/08/10 at 0800 (8:00pm) Braden Scale score 10/High.

Patient #3
Review of the History and Physical for patient #3 reflected the patient was a 70 year old who presented to the hospital's emergency room with a chief complaint of rectal bleeding. Review of the patient's past medical history revealed the patient had a significant history for hypertension, diabetes mellitus type 2 with metabolic syndrome, atherosclerotic cardiovascular disease, paroxysmal atrial fibrillation, history of cystitis and Benign Prostate Hypertrophy (BPH). Documentation in the record reflected the patient was transferred from the emergency room to Intensive Care Unit (ICU).

Review of the medical record reflected the patient had an emergent subtotal Colectomy and splenectomy surgery on 10/3/10. Review of the patient's skin risk assessment on 10/01/10 at 2200 (10:00pm) utilizing the Braden Skin Score reflected patient #3 received a score of 23 which reflected a "standard" level. Interventions for the patient with a "Standard Braden Risk Level" included manage moisture, avoid drying the skin, manage nutrition, maintain good hydration, and manage friction and shear and no massage of reddened bony prominences. Further review of the patient ' s daily skin assessments utilizing the Braden Scale reflected the following Braden skin scores and Braden risk levels, respectively:

10/02/10 at 0705 (7:05 a.m.) Braden skin score 18 / Low;
10/03/10 at 1930 (7:30 pm) Braden skin score 15 / Low;
10/03/10 at 0700 (7:00 am) Braden skin score 16 / Low;
10/04/10 No Braden skin score, however skin documentation for that date at 0400 (4:00 a.m. and 1900 (7:00 pm) revealed the patient had alteration of skin due to a mid abdominal surgical site.
10/ 5/10 at 1505 (3:05 p.m.) Braden skin score 14 / Risk level Medium;
10/05/10 at 1930 (7:30 pm) Braden skin score 18 / Risk level Low;
10/6/10 no documentation of a Braden skin score noted, however documentation of the skin on 10/06/10 at 2030 (8:30 am) reflected the patient ' s skin was dry/flaky and skin turgor was non-elastic.
10/7/10 at 0800 (8:00 am) Braden skin score 12/ Risk level High; Review of the skin documentation reflected there was an alteration of the skin at site #2 which was a skin tear to the right breast that had serosanguinous drainage. Further review reflected the wound bed at the above site red/pink and was a stage II. It was documented at that time that duoderm was applied to site 2 as ordered per S18, Primary Care Physician. Assessment of the skin reflected "weeping" skin appearance and non-elastic skin turgor.
Documentation on 10/8/10 at 0900 (9:00 am) and on 10/9/10 at 0000 (12:00 am) revealed Braden skin score 15/ and a Braden risk level / Low;
Further review of the Braden skin score and Braden risk level for patient #3 reflected the following;
10/9/10 at 0800 (8:00 am) skin score 18 / Low
10/10/10 at 0800 (8:00 a.m.) Braden skin score 20 / Standard
10/11/10 at 0745 (7:45) am Braden skin score 18 / Low
10/11/10 at 1030 Braden skin score 11/ High. It was noted that the patient ' s nutrition was " very poor " , the patient was bedfast with very limited mobility and the patient ' s skin was occasionally moist.
10/12/10 at 0715 (7:15 am) Braden skin score 10 / High.
10/12/10 at 1900 Braden skin score 13 /Medium
10/13/10 at 0730 (7:30) Braden skin score 18 / Low;
10/13/10 at 1400 (2:00 pm) Braden skin score 13 / Medium;
10/14/10 at 0800 (8:00 am) Braden skin score 12 / High;
10/15/10 at 0700 (7:00 am) Braden skin score 14 / Medium;
10/15/10 at 1900 (7:00 pm) Braden skin score 11 / High;
10/16/10 at 0700 (7:00 am) Braden skin score 14 / Medium;
10/17/10 at 0700 (7:00 am) Braden skin score 14 / Medium;
10/17/10 at 0700 (7:00 am) Braden skin score 14 / Medium;
Documentation of the Braden skin score and Braden risk level from 10/18 at 0715 (7:15 am) to 10/20/10 at 1900 (7:00 am) reflected the patient ' s skin score remained between 10 and 12 and the Braden risk level remained high. Further review of Skin Documentation sheet dated 10/19/10 reflected patient #3 had a stage 2 coccyx pressure ulcer which was red/pink in color. There was no documentation to reflect measurements of the ulcer had been done, nor was there documentation of drainage and/or odor to the ulcer. Further review of the record reflected on 10/20/10 the patient had 2 coccyx pressure ulcers. However, there was no description, staging or measurements noted to the pressure ulcers. One pressure ulcer was noted to be at coccyx/sacrum site and one was noted at the coccyx site only.
Further review of the Braden skin score and risk level revealed the following:
10/21/10 at 0700 (7:00am) Braden skin score 9 / Very high;
10/21/10 at 1900 (7:00 pm) Braden skin score 15 / Low
10/22/10 at 0700 (7:00 am) Braden skin score 12 / High;
10/22/10 at 1900 (7:00 p.m) Braden skin score 16 / Low;
10/23/10 at 0700 (7:00 am) Braden skin score 13 / Medium
10/23/10 at 1900 (7:00 pm) Braden skin score 12 / High;
10/24/10 at 0700 (7:00 am) Braden skin score 15 / Low
There was no evidence of a Braden skin score or risk level noted on 10/24/10 a. m.
10/ 25 at 1930 (7:30 am) Braden skin score 16 / Low;
Review of the Braden skin score and Braden risk levels dated from 10/26/10 at 0934 (9:34 am) until 10/29/10 at 0357 (3:57 am) reflected patient #3 ' s Braden skin score ranged from 15 to 17 and the Braden risk level was / Low.
Further review of the skin assessments for patient #3 revealed the following Braden skin score and Braden risk level:
10/29/10 at 0800 (8:00 am) Braden skin score was 13 / Medium;
10/29/10 at 2105 (9:05 pm) Braden skin score 16 / Low;
10/30/10 at 0800 (8:00 am) Braden skin score 13 / Medium;
10/31/10 at 0800 (8:00 am) Braden skin score 11/ High;
10/31/10 at 2000 (8:00 pm) Braden skin score 12 / High;
11/01/10 at 0800 (8:00 am) Braden skin score 12 /High;
Further review of the skin assessment reflected from 11/01/10 to 11/05/10 the Braden skin score ranged from 6 - 11 and the Braden risk level was either very high or high. Review of patient #3's Discharge Summary completed by S18 on 11/5/10 reflected the patient began developing a stage 2 decubitus ulceration involving the sacral perineal region by 10/09/10. Continued review of the Discharge Summary reflected the patient was slowly improving clinically, and the patient was transferred to a Rehabilitation Center.
Review of the Rehabilitation Center's History & Physical Examination dated 11/5/10 at 7:45 pm reflected patient #3 had a stage 3 decubitus with "eschar" and excoriation of sacrum approximately 3' in diameter.


Patient #4
Review of Patient #4's History and Physical performed 11/12/10 revealed he was a 75 year old male admitted on 11/12/10 who had tripped, lost his balance, and fell at home. Further review revealed his fall resulted in respiratory failure following rib fractures from the fall, left lower lobe pneumonia versus contusion, and subcutaneous emphysema. Further review revealed he had a history of hypertension, seizures, and a previous intracerebral aneurysm.

Review of the RN admission assessment performed on 11/12/10 at 3:15am by RN S4 revealed no documented evidence of a weight. Review of the integumentary system section revealed his skin was warm, pale, dry/flaky, edematous, and thin and fragile with elastic skin turgor. Further review revealed he had a large bruise to the left side from a fall and multiple skin tags located on his back. He had slightly limited sensory perception, occasionally moist skin, walked occasionally with slightly limited mobility, adequate nutrition, and potential problem with friction and shear. His Braden skin score was 17/low risk.

Review of the daily skin assessments utilizing the Braden scale performed by the nursing staff for Patient #4 revealed the following results on the following dates:
11/12/10 at 7:15am - Braden skin score 16 / low risk;
11/12/10 at 7:00pm - no documented evidence of an assessment of the Braden skin score and risk;
11/13/10 at 7:15am - Braden skin score 14 / medium risk;
11/13/10 at 11:00pm - Braden skin score 14 / medium risk;
11/14/10 at 7:15am - Braden skin score 14 / medium risk;
11/14/10 at 7:00pm - no documented evidence of an assessment of the Braden skin score and risk;
11/15/10 at 7:45am - Braden skin score 14 / medium risk;
11/15/10 at 7:00pm - no documented evidence of an assessment of the Braden skin score and risk;
11/16/10 at 7:15am - Braden skin score 13 / medium risk;
11/16/10 at 7:30pm - Braden skin score 13 / medium risk;
11/17/10 at 7:15am - Braden skin score 13 / medium risk;
11/17/10 at 8:00pm - Braden skin score 15 / low risk;
11/18/10 at 7:15am - Braden skin score 14 / medium risk;
11/19/10 at 7:00am - Braden skin score 12 / high risk;
11/19/10 at 7:00pm - Braden skin score 15 / low risk;
11/20/10 at 7:00am - Braden skin score 10 / high risk;
11/20/10 at 7:00pm - Braden skin score 14 / medium risk;
11/21/10 at 7:00am - Stage 1 pressure ulcer to buttocks with redness; Braden skin score 11 / high risk;
11/21/10 at 7:00pm - redness to buttocks; Braden skin score 14 / medium risk;
11/22/10 at 7:00am - redness to buttocks; Braden skin score 12 / high risk;
11/22/10 at 7:30pm - redness to buttocks; Braden skin score 9 / very high risk;
11/23/10 at 7:30am - redness to buttocks; Braden skin score 13 / medium risk;
11/23/10 at 7:20pm - redness to buttocks; no documented evidence of an assessment of the Braden skin score and risk;
11/24/10 at 11:11am - redness to buttocks; no documented evidence of an assessment of the Braden skin score and risk;
11/24/10 at 5:13pm - redness to buttocks; no documented evidence of an assessment of the Braden skin score and risk;
11/24/10 at 7:00pm - redness to buttocks; Braden skin score 16 / low risk;
11/25/10 at 7:15am - redness to buttocks; Braden skin score 14 / medium risk;
11/26/10 at 7:00am - redness to buttocks; Braden skin score 12 / high risk;
11/26/10 at 7:00pm - redness to buttocks; Braden skin score 12 / high risk;
11/27/10 at 8:00am - redness to buttocks; Braden skin score 11 / high risk;
11/27/10 at 8:00pm - redness to buttocks; no documented evidence of an assessment of the Braden skin score and risk;
11/28/10 at 7:00am - Stage 1 redness to buttocks; Braden skin score 12 / high risk;
11/28/10 at 8:00pm - redness to buttocks; no documented evidence of an assessment of the Braden skin score and risk;
11/29/10 at 7:00am - Stage 1 redness to buttocks and Stage 1 pressure ulcer to bilateral heels; Braden skin score 11 / high risk;
11/29/10 at 7:15pm - redness to buttocks and pressure ulcer to bilateral heels; Braden skin score 13 / medium risk;
11/30/10 at 8:00am - Stage 1 redness to buttocks and Stage 1 pressure ulcer to bilateral heels; Braden skin score 11 / high risk;
11/30/10 at 8:00pm - redness to buttocks and pressure ulcer to bilateral heels; no documented evidence of an assessment of the Braden skin score and risk;
12/01/10 at 8:00am - Stage 1 pressure ulcer to bilateral heels and no documented evidence of redness to buttocks; Braden skin score 13 / medium risk;
12/01/10 at 7:00pm - redness to buttocks and pressure ulcer to bilateral heels; Braden skin score 13 / medium risk;
12/02/10 at 7:20am - redness to buttocks and Stage 1 pressure ulcer to bilateral heels; Braden skin score 14 / medium risk;
12/02/10 at 7:00pm - redness to buttocks and Stage 1 pressure ulcer to bilateral heels; Braden skin score 15 / low risk;
12/03/10 at 7:20am - Stage 1 redness to buttocks and Stage 1 pressure ulcer to bilateral heels; no documented evidence of an assessment of the Braden skin score and risk;
12/03/10 at 11:00pm - redness to buttocks and Stage 1 pressure ulcer to bilateral heels; Braden skin score 16 / low risk;
12/04/10 at 7:15am - Stage 1 redness to buttocks and no documented evidence of pressure ulcer to bilateral heels; Braden skin score 10 / high risk;
10/25/10 at 7:30am - Stage 1 redness to buttocks, Stage 1 pressure ulcer to bilateral heels, and ecchymosis, edema to scrotum; Braden skin score 11 / high risk;
11/25/10 at 7:00pm - redness to buttocks, ecchymosis and edema to scrotum, and no documented evidence of pressure ulcer to bilateral heels; Braden skin score 11 / high risk;
12/06/10 at 8:38am - redness to buttocks, pressure ulcer to bilateral heel, and ecchymosis and edema to scrotum; Braden skin score 13 / medium risk;
12/06/10 at 3:00pm - Stage 1 redness to buttocks, Stage 1 pressure ulcer to bilateral heels, and ecchymosis, edema to scrotum; Braden skin score 13 / medium risk; and
12/07/10 at 7:30am - Stage 1 redness to buttocks, pressure ulcer to bilateral heels, and ecchymosis and edema to scrotum; no documented evidence of an assessment of the Braden skin score and risk.

Patient #5
Review of Patient #5's History and Physical revealed she was admitted on 10/06/10. Further review revealed she was a 76 year old female with a history of chronic obstructive pulmonary disease, congestive heart failure, Type 2 diabetes, valvular heart disease, and chronic atrial fibrillation. She complained of nausea and abdominal pain, unable to hold down fluids, and had been sick for several days. Further review revealed shingles were present over the left side of the abdomen and extended to the left side of the lumbar and thoracic area.

Review of the admission assessment performed on 10/06/10 at 5:35pm revealed Patient #5 was five feet two inches and weighed 134 pounds. Review of the integumentary section revealed a Stage 1 pressure ulcer to the right heel measuring 4 cm (centimeters) by 2 cm with a red/pink wound bed; a pressure ulcer to the left heel measuring 3 cm by 2 cm with small amount of serous drainage, black eschar to the wound bed, and eschar with redness to the surrounding area; a 1 cm by 1 cm area of circular redness to the inner aspect of the left elbow and a 2 cm by 2 cm bruise right at and above the left elbow; large area of shingles to the abdomen, right flank and back; a 4 cm by 3 cm inflammation with bruising to the posterior thigh (no documented evidence of which thigh); and Stage 2 pressure ulcer to the bilateral buttocks, coccyx with a small amount of serous drainage with a red/pink wound bed (no documented evidence of measurement of the Stage 2 pressure ulcers). Further review revealed the Braden Skin Score was 10 / high risk.

Review of the daily skin assessments utilizing the Braden scale performed by the nursing staff for Patient #5 revealed the following results on the following dates:
10/07/10 at 8:00am - Braden Skin Score 11 / high risk;
10/08/10 at 9:40am - Braden Skin Score 14 / medium risk;
10/09/10 at 9:45am - Braden Skin Score 14 / medium risk;
10/10/10 - no documented evidence of an assessment of a Braden Skin Score and risk;
10/11/10 at 7:30am - Braden Skin Score 12 / high risk;
10/12/10 - no documented evidence of an assessment of a Braden Skin Score and risk;
10/13/10 at 7:30am - Braden Skin Score 12 / high risk;
10/13/10 at 8:40pm - Braden Skin Score 13 / medium risk;
10/14/10 at 7:30am - Braden Skin Score 16 / low risk;
10/15/10 at 8:00am - Braden Skin Score 16 / low risk;
10/15/10 at 8:25pm - Braden Skin Score 12 / high risk;
10/16/10 at 7:55am - Braden Skin Score 13 / medium risk;
10/17/10 at 8:00am - Braden Skin Score 12 / high risk;
10/17/10 at 2:10pm - Braden Skin Score 11 / high risk;
10/18/10 at 7:00am - Braden Skin Score 10 / high risk;
10/18/10 at 8:00pm - Braden Skin Score 13 / medium risk;
10/19/10 at 7:00am - Braden Skin Score 13 / medium risk;
10/20/10 at 7:00am - Braden Skin Score 13 / medium risk;
10/20/10 at 7:00pm - Braden Skin Score 12 / high risk;
10/21/10 at 7:00am - Braden Skin Score 11 / high risk;
10/22/10 at 7:00am - Braden Skin Score 9 / very high risk;
10/23/10 at 7:55am - Braden Skin Score 12 / high risk;
10/24/10 at 8:00am - Braden Skin Score 11 / high risk;
10/25/10 at 7:10am - Braden Skin Score 14 / medium risk;
10/25/10 at 11:00pm - Braden Skin Score 14 / medium risk;
10/26/10 - documented evidence of an assessment of a Braden Skin Score and risk;
10/27/10 at 7:15am - Braden Skin Score 9 / very high risk;
10/28/10 at 7:15am - Braden Skin Score 6 / very high risk;
10/28/10 at 7:00pm - Braden Skin Score 13 / medium risk;
10/29/10 at 7:54am - Braden Skin Score 9 / very high risk;
10/30/10 at 8:00am - Braden Skin Score 11 / high risk;
10/31/10 at 7:30am - Braden Skin Score 14 / medium risk;
11/01/10 at 7:20am - Braden Skin Score 14 / medium risk;
11/02/10 at 12:00am - Braden Skin Score 11 / high risk;
11/02/10 at 7:30am - Braden Skin Score 13 / medium risk;
11/03/10 at 7:40am - Braden Skin Score 14 / medium risk;
11/04/10 at 7:40am - Braden Skin Score 12 / high risk;
11/05/10 at 7:00am - Braden Skin Score 12 / high risk;
11/06/10 at 8:00am - Braden Skin Score 11 / high risk;
11/07/10 at 7:30am - Braden Skin Score 13 / medium risk;
11/07/10 at 7:00pm - Braden Skin Score 11 / high risk; and
11/08/10 at 7:40am - Braden Skin Score 12 / high risk.

Patient #6
Review of the History and Physical (H&P) for Patient #6 dated 09/29/10 revealed a 78 year old male was admitted to the hospital from home with confusion and weakness. Further review revealed Patient #6 had been hospitalized three weeks for altered mental status, myocardial infarction and stenting; however he became too weak to perform ADLs (Activities of Daily Living) and began urinating on himself. He also had a past history of chronic renal failure, diabetes mellitus hypertension and urinary tract infections.

Review of the Adult Admit Assessment dated 09/29/10 revealed at the time of admit Patient #6 weighed 146 pounds. Review of the integumentary system section revealed his skin pink, dry, thin and fragile with tenting. Further review revealed #6 had ecchymosis to the abdomen, back, right hip and suprapubic/right groin, a rash to the perineum, excoriation to the left coccyx and a skin tear to the left elbow. Review of the Braden Scale revealed Patient #6 had slightly limited sensory perception, his skin was rarely moist, walked occasionally, had very limited mobility and had a potential problem for friction and shear. Further he was assessed as a low risk for skin problems

Review of the daily skin assessments utilizing the Braden scale were performed by the nursing staff for patient #10 on the following dates and with the following results:
09/29/10 at 1241 (12:41pm) Braden Scale score 17/Low
09/30/10 at 0007 (12:07am) Braden Scale score 17/Low
10/01/10 at 0000 (12 midnight) Braden Scale score 17/Low
10/01/10 at 0640 (6:40am) Braden Scale score 19/Standard According to documentation in the chart Patient #6 no longer had sensory perception impairment, only slightly limited mobility and had no problem with friction or shear. Further review of the nursing notes dated 10/01/10 revealed patient #6 was on bedrest and had to be turned every two hours.
10/02/10 at 0000 (12 midnight) Braden Scale score 19/Standard
10/02/10 at 0705 (7:05am) Braden Scale score 18/Low
10/02/10 at 2000 (8:00pm) Braden Scale score 18/Low
10/03/10 at 0645 (6:45am) Braden Scale score 14/Medium
10/03/10 at 2000 (8:00pm) Braden Scale score 14/Medium
10/04/10 at 0715 (7:15am) Braden Scale score 14/Medium
10/04/10 at 2353 (12:53am) Braden Scale score 14/Medium
10/05/10 at 0730 (7:30am) Braden Scale score 14/Medium
10/06/10 at 0036 (12:36am) Braden Scale score 14/Medium
10/06/10 at 0710 (7:10am) Braden Scale score 15/Low
10/07/10 at 0735 (7:35am) Braden Scale score 15/Low According to documentation in the nursing notes Patient #6 was assessed to have maceration on the sacrum.
10/07/10 at 2010 (8:10pm) Braden Scale score 15/Low
10/08/10 at 1030 (10:30am) Braden Score scale 15/Low According to documentation in the nursing notes, Patient #6 now has a Stage II decubitus ulcer to the sacrum.

Patient #7
Review of Patient #7's History and Physical revealed she was admitted on 11/17/10. Further review revealed she was a 79 year old who was recently discharged from the hospital following a rather extended stay for ischemic colitis and an upper GI (gastrointestinal) bleed secondary to reflux esophagitis and gastritis. She was doing well until two days earlier when she began to have a recurrence of nausea with some episodic vomiting and feeling generally weak and dizzy.

Review of Patient #7's Discharge Summary revealed she was discharged on 11/29/10 and had acquired a sacral decubitus with some eschar while hospitalized.

Review of the integumentary section of Patient #7's admission nursing assessment revealed her skin was warm, thin, fragile, and wrinkled with ecchymosis to the left arm. Further review revealed she was assessed with a Braden Skin Score of 13 / medium risk. Review of the nursing admission assessment revealed Patient #7 was 5 feet 7 inches and weighed 130 pounds.

Review of the daily skin assessments utilizing the Braden scale performed by the nursing staff for Patient #7 revealed the following results on the following dates:
11/19/10 at 8:00am - Braden Skin Score 13 / medium risk;
11/20/10 at 1:31am - Braden Skin Score 16 / low risk;
11/20/10 at 9:53am - Braden Skin Score 15 / low risk;
11/20/10 at 11:54pm - Braden Skin Score 16 / low risk;
11/21/10 at 8:00am - Braden Skin Score 16 / low risk;
11/21/10 at 8:00pm - Braden Skin Score 16 / low risk;
11/22/10 at 8:00am - Braden Skin Score 14 / medium risk;
11/23/10 at 8:00am - Braden Skin Score 16 / low risk;
11/24/10 at 8:00am - Braden Skin Score 16 / low risk;
11/24/10 at 2:15pm - Braden Skin Score 13 / medium risk;
11/25/10 - no documented evidence of an assessment of a Braden Skin Score and risk;
11/26/10 at 9:00am - Braden Skin Score 14 / medium risk;
11/27/10 at 9:00am - Braden Skin Score 13 / medium risk;
11/28/10 at 4:00pm - Braden Skin Score 12 / high risk; and
11/29/10 at 7:30am - Braden Skin Score 12 / high risk.

Patient #8
Review of Patient #8's medical record revealed she was admitted on 12/07/10 with the admit diagnosis of large diabetic ulcer left foot.

Review of Patient #8's nursing admission assessment performed on 12/07/10 at 5:20pm revealed she was 5 feet 8 inches and weighed 145 pounds. Review of the integumentary section revealed a 5 cm by 4 cm Stage IV wound (no documented evidence that it was a diabetic ulcer) to the left foot with a red/pink wound bed. Further review revealed the Braden Risk Score was assessed as 20 / standard. Review of the skin assessment for 12/08/10 at 8:00am revealed she was assessed with a Braden Skin Score of 19 / Standard.

Patient #9
Review of the History and Physical (H&P) for Patient #9 dated 11/25/10 revealed a 72 year old female was admitted to the hospital from a nursing home with the diagnosis pneumonia. Further review of the medical history revealed #9 had a brain mass, past CVA (Cerebral Vascular Accident), hip and knee contractures, dementia and dysphagia. Further review revealed #9 had a skin breakdown, a Peg tube with protein calorie malnutrition and a very poor underlying condition.

Review of the Adult Admit Assessment dated 11/25/10 revealed at the time of admit Patient #9 weighed 39.57 kg (87 pounds) and was being fed via Peg tube which had continual problems with clogging. Review of the integumentary system section revealed her skin was pale, dry, thin and fragile. Further review revealed #9 had the following identified wounds: #1 left heel-quarter size-eschar to the roof-without drainage; #2 between left great and 2nd toes pressure ulcer Stage II foul smelling drainage; #3 great right toe-pressure ulcer with eschar; #4 inner aspect left foot pressure ulcer healing with granulation (no documented staging of the wound had been performed). Further review revealed #9's sensory perception slightly limited, her skin was occasionally moist, activity was bedfast, was completely immobile, nutrition was probably inadequate and she had a problem with friction and shear.

Review of the daily skin assessments utilizing the Braden scale were performed by the nursing staff for patient #10 on the following dates and with the following results:
11/25/10 at 1348)1:48pm) Braden Scale score 11/High
11/16/10 at 2000 (8:00pm) Braden Scale score 11/High
11/27/10 at 0800 (8:00am) Braden Scale score 12/High
11/28/10 no documented evidence a skin assessment had been performed
11/29/10 at 2000 (8:00pm) Braden Scale score 10/High
11/30/10 at 0810 (8:10am) Braden Scale score 11/High
11/30/10 at 2010 (8:10pm) Braden Scale score 13/Medium
12/01/10 at 0800 (8:00am) Braden Scale score 10/High
12/02/10 at 0800 (8:00am) Braden Scale score 11/High
12/03/10 at 0800 (8:00am) Braden Scale score 12/High
12/04/10 at 0800 (8:00am) Braden Scale score 12/High
12/05/10 at Midnight Braden Scale score 9/Very High
12/05/10 at 1558 (3:58pm) Braden Scale score 12/High
12/06/10 at 0030 (12:30am) Braden Scale score 6/Very High
12/07/10 at 0800 (8:00am) Braden Scale score 8/Very High
12/07/10 at 2000 (8:00pm) Braden Scale score 10/High
12/08/10 at 0800 (8:00pm) Braden Scale score 10/High

Patient #10
Review of the History and Physical (H&P) for Patient #10 dated 11/17/10 revealed a 79 year old male was admitted to the hospital from a nursing home with the diagnosis of a left knee effusion with lower left cellulitis. Further review of the medical history revealed profound mental retardation, peripheral vascular disease, chronic anemia and chronic kidney disease.

Review of the Adult Admit Assessment dated 11/18/10 revealed at the time of admit Patient #10 weighed 60.32 kg (132.7 pounds) and was being fed via Peg tube. Review of the integumentary system section revealed his feet were dry and scaly and a left foot ulcer which was healing (no documented evidence staging of the ulcer had been performed). Further review revealed #10's sensory perception was very limited, his skin was occasionally moist, was bedfast with very limited mobility, poor nutrition and friction/shear to the skin a potential problem

Based on record review and interview the hospital failed to ensure all care plans had documented interventions to assist in achieving the documented goals, date(s) for targeted achievement, were updated as the needs and condition of the patients changed, and were assessed for completion before discharge for 7 of 10 sampled patients all of whom had care plans (#2, #4, #6, #8, #7, #9, #10). Findings:

Patient #2
Review of the History and Physical (H&P) for Patient #2 dated 12/02/10 revealed a 60 year old female was admitted to the hospital from a nursing home with the diagnoses of pyuria, bacteremia and a very high sodium level consistent with free water deficit. Further review of the medical history revealed #2 had Down's Syndrome, seizure disorder, diabetes mellitus, decubiti and previous amputations. Her level of consciousness and appetite had also decreased.

Review of the Plan of Care for Patient #2 dated 12/02/10 revealed the following identified problems: impaired gastrointestinal function; impaired genitourinary function; impaired neurological function; related care of mid adult; nutritional function; impaired musculoskeletal function; speech/swallow function; discharge planning; isolation; impaired cardiovascular function; and impaired EENT (Eyes Ears Nose Throat). Further review of the medical record revealed no documented evidence of target dates or if the goals had been accomplished before discharge.

Patient #4
Review of Patient #4's History and Physical performed 11/12/10 revealed he was a 75 year old male admitted on 11/12/10 who had tripped, lost his balance, and fell at home. Further review revealed his fall resulted in respiratory failure following rib fractures from the fall, left lower lobe pneumonia versus contusion, and subcutaneous emphysema. Further review revealed he had a history of hypertension, seizures, and a previous intracerebral aneurysm.

Review of the integumentary section of the RN admission assessment performed on 11/12/10 at 3:15am by RN S4 revealed his skin was warm, pale, dry/flaky, edematous, and thin and fragile with elastic skin turgor. Further review revealed he had a large bruise to the left side from a fall and multiple skin tags located on his back. Further review of the care plan established upon admit revealed the following problems: impaired respiratory function, impaired cardiovascular function, impaired genitourinary function, and a high risk for pneumonia.

Review of the skin assessments for Patient #4 revealed he developed a Stage I pressure ulcer to the buttocks on 11/21/10 at 7:00am and a Stage I pressure ulcer to bilateral heels on 11/29/10. Review of the entire medical record revealed Patient #4's care plan was not updated to include the problem of impaired skin integrity until 11/27/10.

Patient #5
Review of the History and Physical (H&P) for Patient #5 dated 11/12/10 revealed a 75 year old man admitted to the hospital care due to a fall resulting in fractures ribs, respiratory distress and subsequent intubation. Further review revealed he had a history of a cerebral aneurysm with previous surgery for an aortic abdominal aneurysm, hypertension, COPD (Chronic Obstructive Pulmonary Disease), and a suprapubic catheter.

Review of the Nursing Assessment for Patient #5 dated 11/21/10 revealed he had been assessed with a Stage I pressure ulcer to the buttocks. Further review of the medical record revealed no documented evidence Patient #5 had been care planned for the decubitus ulcer until 11/25/10.

Patient #6
Review of the History and Physical (H&P) for Patient #6 dated 09/29/10 revealed a 78 year old male was admitted to the hospital from home with confusion and weakness. Further review revealed Patient #6 had been hospitalized three weeks for altered mental status, myocardial infarction and stenting; however he became too weak to perform ADLs (Activities of Daily Living) and began urinating on himself. He also had a past history of chronic renal failure, diabetes mellitus hypertension and urinary tract infections.

Review of the Plan of Care for Patient #6 dated 09/29/10 revealed the following identified problems: cardiovascular function; developmental age for older adult; discharge planning; impaired gastrointestinal function; impaired EENT (Eyes Ears Nose Throat); impaired musculoskeletal function; impaired neurological functions; impaired genitourinary function; isolation precautions; impaired skin; and evaluate for PT/OT needs (Physical/Occupational Therapy). Further review of the medical record revealed no documented evidence of interventions, target dates or if the goals had been accomplished before discharge.

Patient #7
Review of the History and Physical (H&P) for Patient #7 dated 11/17/10 revealed a 79 year old white female who had recently been discharged from the hospital following a rather extended stay for ischemic colitis and an upper GI (Gastro-Intestinal) bleed secondary to reflux esophagitis and gastritis. Further review revealed Patient #7 had to be readmitted due to nausea, episodic vomiting, weakness and dizziness.

Review of the Plan of Care for Patient #7 dated 11/18/10 revealed the following identified problems: impaired gastrointestinal function; impaired skin; nutritional function; discharge planning; impaired neurological function; impaired musculoskeletal function: risk for fall; risk for pneumonia; and impaired genitourinary function. Further review of the medical record revealed no documented evidence of interventions, target dates or if the goals had been accomplished before discharge.

Patient #8
Review of the Physician's Orders dated 12/07/10 revealed Patient #8, a 53 year old male was admitted to the hospital with the diagnosis of a diabetic foot ulcer.

Review of the Care Plan for Patient #8 revealed the plan had been initiated on 12/07/10 with the following problems identified: Discharge Planning; Nutritional function; and Impaired skin; Pain management. Further review revealed no documented evidence a target date for reaching the goal had been determined.

Patient #9
Review of the History and Physical (H&P) for Patient #9 dated 11/25/10 revealed a 72 year old female was admitted to the hospital from a nursing home with the diagnosis pneumonia. Further review of the medical history revealed #9 had a brain mass, past CVA (Cerebral Vascular Accident), hip and knee contractures, dementia and dysphagia. Further review revealed #9 had a skin breakdown, a Peg tube with protein calorie malnutrition and a very poor underlying condition.

Review of the Plan of Care for Patient #9 dated 11/25/10 revealed the following identified problems: age related care for older adult; discharge planning needs; needs assessment for speech/swallow; risk for fall; , impaired gastrointestinal function; impaired musculoskeletal function; impaired genitourinary function; risk for fall; need for post-operative care; needs assessment for speech/swallow function; impaired neurological function; nutritional function; musculoskeletal function; impaired cardiovascular function; and impaired respiratory function; impaired skin; risk for DVT (Deep Vein Thrombosis); pain management; and contact precautions. Further review of the medical record revealed no documented evidence of interventions, target dates or if the goals had been accomplished before discharge.

Patient #10
Review of the History and Physical (H&P) for Patient #10 dated 11/17/10 revealed a 79 year old male was admitted to the hospital from a nursing home with the diagnosis of a left knee effusion with lower left cellulitis. Further review of the medical history revealed profound mental retardation, peripheral vascular disease, chronic anemia and chronic kidney disease.

Review of the Plan of Care for Patient #10 dated 11/18/10 revealed the following identified problems: altered development, impaired gastrointestinal function; impaired musculoskeletal function; impaired genitourinary function; risk for fall; need for post-operative care; needs assessment for speech/swallow function; nutritional function; musculoskeletal function; speech/swallow function; discharge planning; isolation; impaired cardiovascular function; and impaired psychological function; impaired skin; high risk for pneumonia; impaired EENT (Eyes Ears Nose Throat). Further review of the medical record revealed no documented evidence of interventions, target dates or if the goals had been accomplished before discharge.

In a face-to-face on 12/08/10 at 1:30pm, Director of Nursing Practice S22 confirmed the care plan for Patient #4 was not updated until 11/27/10 to include the problem with skin integrity after the pressure ulcer was identified on 11/21/10.

Review of the hospital policy titled "Care Planning - Nursing/Ancillary Departments", revised 07/10 and submitted by Risk Manager S14 as their current policy for care plans, revealed, in part, "...An essential element in the planning process is assessment of the severity of the patient's disease, condition, impairment, or disability. Patient's care, treatment, and rehabilitation goals are identified as an integral part of the care planning process. ... Each patient's progress is periodically evaluated by nursing against care goals and the plan of care and when indicated, the plan or goals are revised/modified to meet the individual needs of the patient...".


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Based on record review and interview, the hospital failed to ensure the nursing staff had been assessed for competency by having 1 of 2 LPNs (licensed practical nurse) reviewed for competency from a total of 13 LPNs assigned to the 4 East floor with no documented evidence of competency assessment by a RN (registered nurse) (S10). Findings:

Review of LPN S10's "RRMC RN / LPN (Rapides Regional Medical Center Registered Nurse / Licensed Practical Nurse) Core Competency" revealed she was assessed on 10/14/10 by LPN S5 for the following: completes patient assessment as per hospital policy; plans care based on assessment findings; educates patient and family; makes entry in record as per policy; adheres to National Patient Safety Goals; follows ethics policy when dealing with ethical dilemma; and reports serious preventable adverse events. Further review revealed LPN S10 was assessed on 10/13/10 by LPN S5 for the following: pain assessment and reassessment policy; responds to medical emergency; participates in department/unit activities for performance improvement; patient rights; provides a complete patient report with hand off communication; and performing/knowledge of glycemic control, IV (intravenous) therapy/insertion/pump, restraint use, fall prevention, wound/skin care, chest tubes, DVT (deep vein thrombosis) prevention, oxygen therapy, core measures, and central lines. Further review revealed no documented evidence that a RN had assessed LPN S10's competency for the above-mentioned areas/skills.

In a face-to-face interview on 12/09/10 at 3:05pm, Clinical Educator S16 confirmed LPN S10's competency assessment had been performed by LPN S5 and not a RN.

Review of the hospital policy titled "Staff Competence", revised 02/07 and submitted by Risk Manager S14 as their current policy for staff competency, revealed, in part, "...For the purpose of this policy, competence is the ability of the employee to perform in a specific role by exhibiting the knowledge, skills, behaviors and personal characteristics necessary to function appropriately in a given role to meet specified job responsibilities and requirements. ... All managers or their designee are responsible for validating the competence of the employees they manage, maintaining comprehensive activities for departmental and job specific initial orientation, and establishing a plan to meet the continuing education needs of all personnel in the department. ... The hospital periodically reviews the staff's abilities to carry out job responsibilities, especially when introducing new procedures, techniques, technology, and equipment. ... Mechanisms for validating competence may include but are not limited to: a. Check lists with skill validation for technical procedures and activities; b. Demonstrated interpersonal and critical thinking ability; c. Validation of age-specific competencies; d. Direct observations by managerial staff; e. Self-assessment tools; f. Peer review; g. Experiential review; and h. Assessment of ability to perform skills within their department that are high volume, high risk, and/or problem prone".

Based on record review and interview, the hospital failed to ensure the physical therapy services were provided by physical therapists determined to be competent by having 1 of 3 physical therapists whose personnel files were reviewed with competency assessed by chart review rather than direct observation of job performance (S12). Findings:

Review of Physical Therapist (PT) S12's "Annual Competency Assessment (Physical Therapist) Procedures" revealed S12's competency for pediatric, adolescent, adult, and geriatric knowledge and skills was assessed by PT S13 on 04/03/10, 04/04/10, and 04/28/10 by chart review. Review of the "Annual Competency Assessment (Physical Therapist) Safe Use of Equipment" revealed S12's competency for safe use of equipment was assessed by PT S13 04/03/10 and 04/28/10 by chart review. Further review revealed no documented evidence of direct observation of PT S12 performing his job duties by PT S13.

In a face-to-face interview on 12/09/10 at 1:40pm, Director of Rehab S15 indicated she was in the process of revising the competency checklist, because she didn't like the present form. She further indicated she could not assure a PT's competency by performing chart reviews and not having direct observation of the PT performing his job duties.

Review of the hospital policy titled "Staff Competence", revised 02/07 and submitted by Risk Manager S14 as their current policy for staff competency, revealed, in part, "...For the purpose of this policy, competence is the ability of the employee to perform in a specific role by exhibiting the knowledge, skills, behaviors and personal characteristics necessary to function appropriately in a given role to meet specified job responsibilities and requirements. ... All managers or their designee are responsible for validating the competence of the employees they manage, maintaining comprehensive activities for departmental and job specific initial orientation, and establishing a plan to meet the continuing education needs of all personnel in the department. ... The hospital periodically reviews the staff's abilities to carry out job responsibilities, especially when introducing new procedures, techniques, technology, and equipment. ... Mechanisms for validating competence may include but are not limited to: a. Check lists with skill validation for technical procedures and activities; b. Demonstrated interpersonal and critical thinking ability; c. Validation of age-specific competencies; d. Direct observations by managerial staff; e. Self-assessment tools; f. Peer review; g. Experiential review; and h. Assessment of ability to perform skills within their department that are high volume, high risk, and/or problem prone".

Based on record review and interview, the hospital failed to ensure rehab services were provided as ordered by the physician as evidenced by PT (physical therapy)/OT (occupational therapy) treatments plans with a frequency less than what was ordered by the physician and/or treatment plans with no documented evidence of duration, interventions, patient-specific measurable goals, and physician notification of discharge from PT/OT services as required by standards of physical therapy practice for 3 of 5 patients reviewed with rehab services from a total of 10 sampled patients (#1, #5, #7). Findings:

Patient #1
Review of Patient #1's medical record revealed she was admitted on 12/01/10 at 2:03pm. Review of the H&P (history and physical) dictated on 12/02/10 by Physician S18 revealed her chief complaint was shortness of breath. Further review revealed the clinical impression was as follows: acute bronchitis, possible bronchopneumonia; remote history of eosinophilic pneumonitis with questionable history of interstitial lung disease; chronic hypoxic respiratory insufficiency requiring oxygen supplementation; history of CHF (congestive heart failure) due to diastolic dysfunction with a component of coronary disease and prior coronary artery stents; history of anemia; and history of progressive weight gain with severe generalized deconditioning.
Review of the "Physician's Orders" revealed an order on 12/02/10 at 8:20pm for PT to evaluate and treat - ambulate in hallway with oxygen please BID (twice a day).
Review of the PT evaluation performed by PT S11 on 12/03/10 revealed physical therapy was to begin 12/03/10 with a frequency of 5 times a week for 15 minutes for progressive mobility training with portable oxygen. Further review revealed goals were supervision with gait training pattern 200 feet with portable oxygen and independent mobility functional household distances. Further review revealed all short term goals were to be accomplished in 5 days and all long term goals were to be accomplished in 2 weeks. There was no documented evidence which goals were short term and which goals were long term. There was no documented evidence that the physician orders for ambulation twice a day were implemented in the PT treatment plan, as the plan was for 5 times a week for 15 minutes.
Review of the medical record revealed Patient #1 received PT on 12/03/10 at 9:30am and at 2:15pm and on 12/06/10 at 11:45am. There was no documented evidence of PT visits on 12/04/10 and 12/05/10.

Patient #5
Review of Patient #5's medical record revealed she was admitted on 10/06/10 with diagnoses of atrial fibrillation with rapid ventricular response, dehydration, electrolyte imbalance, and Coumadin toxicity.
Review of Patient #5's physician orders revealed the following orders:
10/07/10 at 5:00pm - physical therapy to help to enable patient sit up on chair as long as tolerated;
10/08/10 at 7:00am - PT consult for gait training;
10/14/10 at 7:20am - up in chair BID (twice a day);
10/23/10 at 11:25am - PT / OT consult if not already receiving services;
11/05/10 at 5:12pm - PT / OT consult.
Review of the PT initial evaluation performed by PT S23 on 10/08/10 at 10:10am revealed the short term goals were: patient standby assistance with bed mobility, minimal assist with supine to sit, and assess standing. Further review revealed the short term goals were to be met in 5 days. Review of the long term goals revealed patient was to be independent with sitting at edge of bed in 3 weeks. The treatment plan established by PT S23 was for PT 5 times a week with daily treatments for 15 minutes. Further review revealed no documented evidence of the treatment interventions, the duration of treatment, and the means of measuring to determine when Patient #5 would meet the established goals. Review of the medical record revealed Patient #5 refused PT treatment on 10/11/10 at 11:38am and 10/11/10 at 3:26pm. Further review revealed a PT discharge summary completed on 10/12/10 at 11:24am. Review of the discharge summary revealed, in part, "...patient continues to refuse therapy attempts. States that she lives at home and is bed bound at home. ...stated that she will not participate with therapy. ...will speak with case management ...". Further review of the medical record revealed no documented evidence the physician was notified of Patient #5's continued refusal of PT services and her subsequent discharge from PT services.
Review of Patient #5's medical record revealed documentation on 10/24/10 at 10:20am that "occupational therapy orders received. Patient has now been reintubated since orders written. Occupational therapy will hold until further orders". Further review revealed no documented evidence of communication with the physician and an order to hold OT services.
Review of Patient #5's medical record revealed documentation by PT S23 on 10/25/10 at 8:45am of "patient has been placed on the vent since orders received. Patient is medically not stable to participate with therapy at this time". Further review revealed no documented evidence of communication with the physician and an order to cancel or hold PT services.
Review of Patient #5's medical record revealed a PT evaluation was performed on 11/06/10 at 12:45pm by PT S12. Review revealed the treatment plan was for PT 5 times a week with daily treatment for 20 minutes. Further review revealed no documented evidence of the treatment interventions and the duration of treatment. Review of the short term and long term goals revealed the same goals for each, with the only difference being the short term goal was to improve static/dynamic sitting balance to fair, and the long term goal was to improve static/dynamic sitting balance to fair + (plus). The two other goals, both short term and long term, were for bed mobility to go from supine to sit and sit to supine with minimal assistance of two and minimal assistance with stand pivot transfer to bedside commode or chair. Further review revealed no documented evidence of determining how sitting balance would be measured. Further review revealed the short term goals were to be met in 5 days, and the long term goals were to be met in 4 weeks. Further review revealed no explanation of the need for bed mobility and transfers to be long term goals to be met in 4 weeks when they were to be met in 5 days as short term goals.
Review of the medical record revealed documentation by PT S24 on 11/08/10 at 11:17am of "patient re-evaluated over the weekend. However, patient was bed bound prior to this hospital stay and therefore continues to have a lack of goals for skilled pt (patient). Patient loves to do ROM (range of motion) exercises, but this can be done with nursing ...and does not require the skills of a therapist. Patient to be D/C (discharged) from PT". Further review revealed no documented evidence of communication with the physician and an order to cancel PT services.
Review of the OT initial evaluation performed on 11/07/10 revealed the plan was for OT 3 days a week for 15 minutes as tolerated. Further review revealed no documented evidence of the duration of treatment and the treatment interventions to be performed by OT. Review of the short term goals revealed the following goals: 1) educate patient on elevation of the left hand onto a pillow to facilitate reduction of swelling; 2) educate patient on passive, active, and active assistive range of motion of left joints of the hand to facilitate movement and to decrease swelling; and 3) patient will assist in holding her hands into a small basin of water to soak. Further review revealed the goals were actually goals for the OT and not goals for the patient. Further review revealed no documented evidence of time frames for the short term and long term goals to be met.

Patient #7
Review of Patient #7's medical record revealed she was admitted on 11/17/10 with the diagnosis of upper gastrointestinal (GI) bleed and generalized weakness. Further review revealed an order on 11/22/10 at 8:00am for PT to evaluate and treat. Further review revealed an order on 11/26/10 at 8:30am for PT/OT consult for ambulation.
Review of Patient #7's initial PT evaluation performed on 11/22/10 at 2:20pm revealed goals of patient will perform bed mobility and transfer with moderate assistance and patient will ambulate 10 feet with rolling walker and minimal assistance times 2. Further review revealed short term goals were to be accomplished in 1 week, and long term goals were to be accomplished in 2 weeks. Further review revealed no documented evidence which goals were short term and which goals were long term, and there was no indication how bed mobility and transfer would be measured to determine when the goal would be met.
Review of the medical record revealed documentation on 11/26/10 at 2:13 of "OT will defer to PT to address ambulation/mobility needs". There was no documented evidence of communication with the physician and an order to cancel OT services.
Review of the PT reassessment summary performed on 11/26/10 at 2:15pm revealed the same goals and treatment established on the previous evaluation of 11/22/10 with no documented evidence which goals were short term and which goals were long term, and there was no indication how bed mobility and transfer would be measured to determine when the goal would be met. Further review revealed no documented evidence of PT treatment on 11/27/10 and 11/28/10.

In a face-to-face interview on 12/09/10 at 1:40pm, Director of Rehab S15 indicated the PT evaluates the patient, and the physician was supposed to read the plan established by PT. Regarding Patient #1 not being seen on 12/04/10 and 12/05/10, S15 indicated the PTs do not see patients on the weekend other than orthopedic patients and new evaluations. S15 confirmed Patient #7's treatment plan did not include the duration of treatment and the modalities to be performed by the PT. S15 indicated the therapists do not call the physician every time they make a change to the physician ' s orders for the patient.

In a face-to-face interview on 12/10/10 at 11:25am, Director of Rehab S15 indicated the OT did not perform an evaluation as ordered by the physician for Patient #7, and she confirmed the physician was not notified.

Review of the hospital policy titled "Patient Assessment and Reassessment", revised 02/10 and submitted by Risk Manager S14 as their current policy for assessments, revealed, in part, "...Rehabilitation Services ... The functional assessment should identify the patient's physical, cognitive, behavioral, communicative, emotional, and social status and any facilitating factors that may influence attainment of rehabilitation goals. ...Based upon the outcome the assessment a rehabilitation plan of care is developed in collaboration with the patient's physician, other caregivers, and the patient ...".

Review of the "World Confederation for Physical Therapy (WCPT) Position Statement - Standards of Physical Therapy Practice", adopted at the 16th WCPT General Meeting June 2007, revealed, in part, "The World Confederation for Physical Therapy (WCPT) aims to improve the quality of global healthcare by encouraging the high standards of physical therapy education and practice. ... These standards are considered to be achievable Standards of practice. They are presented as ideal standards to which all physical therapists should aspire as part of their professional responsibility. ...The physical therapist communicates and coordinates all aspects of patient/client management including the results of the initial examination/assessment and evaluation, diagnosis, prognosis, plan of care/intervention/treatment, response to interventions/treatment, changes in patient/client status relative to the interventions/treatments, re-examination, and discharge/discontinuation of the intervention/treatment and other patient/client management activities. ...The physical therapist, when communicating with members of a multiprofessional team providing services for the patient/client, ensures that information is sought and communicated promptly and clearly within the team, and a system exists for written communication with other members of the team. ...The plan of care/intervention/treatment ...describes the proposed intervention/treatment, including frequency and duration ...".