HospitalInspections.org

Based on clinical record review, policy and procedure review and interviews, it was determined the Facility failed to ensure policies and procedures, orientation material and the patient care components built into the electronic medical record (EMR) were organized into a congruent and cohesive framework. Failure to ensure policies and procedures, orientation material and EMR patient care components meshed had the potential to allow staff confusion regarding how and when patient care was rendered and documented. The failed practice affected Patient #2, #8 and #9. Findings follow:


A. Review of the policy and procedure titled Restraints/Seclusion revealed the following:...

#8 DOCUMENTATION IN THE ELECTRONIC HEALTH RECORD INCLUDES AT A MINIMUM...

8.6 MONITORING/ASSESSMENT/REASSESSMENT/CARE
· Monitoring, assessment, reassessment, and care provided
- Monitoring documentation required for patients in leather/locked restraint or seclusion is every 15 minutes.
- Monitoring documentation requirements for non-violent/non self-destructive restraint is at a minimum of once per shift...


B. Review of the Restraint/Seclusion Section in the Nursing Orientation Manual revealed the following under Documentation:
· RN (Registered Nurse) Ongoing documentation:
- Nursing Observation & Monitoring
· Once per shift minimum for acute care
· Every four hours in ICU (Intensive Care Unit)
· Justification for continued use...


C. Review of the restraint section in the EMR revealed the check and documentation of restrained patients was prompted every two hours.


D. During an interview with RN #4 at 1210 on 08/07/15 he was asked how often restrained patients were checked. RN #4 stated he checked restrained patients every two hours as prompted by the EMR flowsheet but documented only at 0700, 1100 and 1500.


E. Review of Patient #9's clinical record revealed restraint documentation on 07/19/15 was every four hours, from 07/20/15 through 07/23/15 was every two hours, every four and three hours on 07/24/15 and 07/25/15 and every four hours on 07/30/15 and 07/31/15. Patient #9 was restrained without a physician's order on 08/01/15.


F. During an interview with Executive Director of Nursing #1 and #2 at 1310 on 08/07/15 they both stated restrained patients should be checked every two hours and the checks documented every two hours.


G. Review of the policy and procedure titled Pressure Ulcers (Stages I-IV) Skin Care revealed the following:

#1 POLICY

1.1 Nursing will be responsible for preventive care and management of pressure ulcers. Other health care teams will also share in the responsibility.

1.2 All patients will have a skin risk assessment done within 8 hours of admission and every shift.

1.3 The Braden Scoring System will be used to assess pressure ulcers...

#6 PREVENTION OF PRESSURE ULCERS

6.1 Institute measures to reduce and/or relieve pressure...

#7 CARE OF PRESSURE ULCERS...

7.5 Reduce Pressure
· Initiate turn schedule
· Use bridging techniques:...
7.10 Document in the Electronic Health Record
· Skin Assessment findings
· Stage, location, size (in cm - centimeters), depth, exudate, odor, wound color, any treatment and any undermining or tracking.


H. Review of the Nursing Orientation Manual received from the Risk Manager at 1330 on 08/04/15 revealed the following under the Pressure Ulcer/Wound Care Section:

1. Wound Assessment Parameters (with an explanation for each parameter): Location, Wound Size, Wound Base, Drainage, Odor, Wound Edges, Peri-wound Edges, Pain, Edema and Pulses.

2. TURN SHEET, Turn every 2 hours and indicate position. Turn sheet contains sections for 24 hour documentation of position patient in and if the patient is out of bed, in the chair and heels bridged.


I. A group interview was conducted at 1215 on 08/05/15.

1.During the group interview the Wound Care Nurse at 1220 on 08/05/15 stated Patient #2 should have been turned every two hours.

2.During the group interview the Executive Director of Nursing #1 stated the skin assessment was part of the nursing assessment and should have included the wound location, size, undermining, drainage and a description of the wound.

3.Executive Director of Nursing #2 stated the Facility set 18 as the score at which the Pressure Ulcer Risk Reduction protocol was to be implemented and 14 as the score at which the Pressure Ulcer Care Plan was automatically applied to the Nursing Care Plan.


J. Interviews were conducted with Facility staff:

1. During an interview with the Director of Quality at 1150 on 08/05/15 stated when the Braden Score is 14 the Skin Care Protocol should be initiated. A score of 14 automatically applied the Pressure Ulcer Care Plan to the care plan.

2. During an interview with RN #5 at 0820 on 09/07/15 stated wounds should be measured every shift and patients with wounds should be turned every two hours.

3. During an interview with RN #4 at 1210 on 08/07/15 he was asked at what number of the Braden Score was the Pressure Ulcer Risk Reduction protocol implemented and he stated he wasn't sure but he knew Patient #9 was to be turned every two hours.

4. During an interview with RN #6 at 1215 on 08/07/15 he was asked at what number of the Braden Score was the Pressure Ulcer Risk Reduction protocol implemented. RN #6 did not answer the question but stated it did not matter, he turned all of his patients every two hours to prevent skin breakdown.


K. Review of Patient #2's clinical record revealed he was admitted to the Facility on 02/21/15. Review of the initial nursing assessment authored by Registered Nurse (RN) #1 and #2 revealed documentation identifying three wounds as present on admission: coccyx and left heel documented as ulceration, right heel as present. Review of the clinical record revealed documentation by the Wound Care Nurse on 02/25/15 at 1050 that stated the following: "Ulcer is documented as POA (present on admission). Exam done. Sacrum/coccyx has an area of dark unblanchable purpura which measures 13 cm long x (by) 17cm wide with minimal depth and dark purple wound base. Deep tissue injury. Suspect evolving stage III-IV. Review of the clinical record revealed no other nursing documentation describing the wound including measurements. Review of the clinical record revealed Patient #2's initial Braden score was 15. Patient #2's Braden Scores ranged from a low of 10 on 03/04/15 at 0700 to a high of 18 on 03/05/15 at 0638. There was no evidence the Pressure Ulcer Risk Reduction Protocol was initiated. Review of the clinical record revealed no documentation Patient #2 was turned every two hours from 02/22/15 through discharge on 03/17/15. The above was verified by the Director of Quality and Clinical Informatics Nurse at 1120 on 08/05/15.


L. During an interview with the Wound Care Nurse at 1220 on 08/05/15 she stated Patient #2 should have been turned every two hours and wounds assessed, described and measured every shift per policy and procedure.


M. Review of Patient #9's clinical record revealed he was admitted to the Facility on 07/13/15. Review of the clinical record revealed Patient #9 had no skin issues at admission and Braden Score on 07/14/15 on the 7AM (Ante Meridian) to 7 PM (Post Meridian) shift was 19 and 18 on the 7 PM to 7AM shift at which time the Pressure Ulcer Risk Reduction Protocol should have been initiated. On 07/15/15 the Braden Score was documented as 12 and then again as 13 on the 7 AM shift and as 8 on the 7PM shift. Review of the clinical record revealed no documentation Patient #9 was turned every two hours from 07/14/15 through 08/06/15. Review of the clinical record revealed Patient #9's Braden Score was never above 15 from 07/15/15 until 08/06/15.

During an interview with the Executive Directors of Nursing #1 and #2 at 1330 on 08/07/15 they both verified the above findings and stated Patient #9 should have been turned every two hours at the point his Braden Score reached 12 on 07/15/15.

Based on clinical record review, interview and policy and procedure review, it was determined a Registered Nurse failed to evaluate and provide nursing care in accordance with physician's orders and policy and procedure in that daily baths, daily weights, intake and output notification, antibiotics, supplements and dressing changes were not performed for six (#2-#4, #6, #8 and #9) of ten (#1-#10) patients. Failure to provide nursing care per physician's orders and policy and procedure did not allow the patients to attain the highest level of care to promote health and wellness and prevent decline of the patient's physical condition. The failed practice affected Patients #2, #3, #4, #6, #8 and #9 on 08/07/15. Findings follow:


A. Review of the policy and procedure titled Baths revealed the following:

Overview: The bath provides cleanliness, comfort and stimulates circulation of the skin. It is an excellent opportunity for patient assessment and individualized attention to physiologic and psychological needs. Exercise is provided by patient participation and range of motion. NOTE: The time of the daily bath should be determined by the patient's needs ....

#4 DOCUMENTATION
4.1 Document bath in the electronic health record.
4.2 If patient refuses a bath, document in the electronic health record and notify the RN (registered nurse).


B. Review of the clinical records of Patient #2 revealed no evidence a daily bath was given or refused on 7 (02/26/15, 03/01/15, 03/03/15, 03/07/15, 03/11/15, 03/12/15, and 03/17/15) of 24 days (02/22/15 through 03/17/15). During an interview with the Director of Quality and Clinical Informatics Nurse at 1115 on 08/05/15 they verified the above findings.


C. Review of the clinical record of Patient #6 revealed no evidence a daily bath was given or refused on 3 (07/31/15, 08/04/15 and 08/05/15) of 7 days (07/31/15 through 08/06/15). During an interview with the Clinical Informatics Nurse at 1045 on 08/07/15 she verified the above findings.


D. Review of the clinical record of Patient #9 revealed no evidence a daily bath was given or refused on 9 (07/14/15, 07/19/15 - 07/23/15, 07/26/15, 07/28/15, 07/31/15 and 08/05/15) of 24 days. During an interview with the Director of Quality at 1050 on 08/07/15 she verified the above findings.


E. Review of the physician's orders dated 07/20/15 for Patient #4 revealed orders for daily weights. Review of the clinical record revealed no evidence Patient #4 was weighed 12 (07/21/15-07/26/15, 07/29/15-07/31/-15, 08/02/15, 08/05/15 and 08/06/15) of 17 (07/21/15-08/06/15) days. During an interview with Clinical Informatics Nurse at 0930 on 08/07/15 she verified the above findings.


F. Review of the physician's orders dated 01/20/15 for Patient #3 revealed orders for strict intake and output measurement every 8 hours and to call the physician if output was < (less than) 240 mls (milliliters). Two of two times (01/21/15 at 0955 and 01/22/15 1932) the output was less than 240 mls and there was no evidence the physician was notified. During an interview with Clinical Informatics Nurse at 1010 on 08/07/15 she verified the above findings.


G. Review of the physician's orders dated and timed 02/24/15 at 0714 for Patient #2 revealed Zosyn 2.25 Gm (grams) to be administered IV (intravenously) every 8 hours. Review of the Medication Administration Record (MAR) revealed no evidence Patient #2 received Zosyn every 8 hours on 02/24/15, 02/25/15 and 02/26/15. During an interview with the Director of Quality and Clinical Informatics Nurse at 1450 on 08/05/15 they verified the above findings.


H. Review of the physician's orders dated and timed 07/21/15 at 2241 for Patient #4 revealed Vancomycin 250 mg (milligram) every six hours. Review of the MAR revealed on 07/23/15, 07/25/15, 07/26/15, 07/27/15, 07/28/15, 07/31/15 and 08/01/15 the Vancomycin was given in intervals ranging from 3 to 10 hours between doses. During an interview with Clinical Informatics Nurse at 0910 on 08/07/15 she verified the above findings.


I. Review of the physician's orders dated and timed 03/02/15 at 0626 for Patient #2 revealed orders for Nepro supplement twice a day. Review of the clinical record revealed no evidence the Nepro was given twice a day from 03/02/15 through 03/17/15. During an interview with Clinical Informatics Nurse at 1415 on 08/15/15 she verified the above findings.


J. Review of the physician's orders dated and timed 07/29/15 at 1212 revealed orders for Ensure supplement with meals. Review of the clinical record revealed no evidence the Ensure was given every meal from 07/29/15 through 08/06/15. During an interview with Clinical Informatics Nurse at 1310 on 08/07/15 she verified the above findings.


K. Review of the physician's orders dated 07/20/15 for Patient #4 revealed orders for Ensure supplement with meals. Review of the clinical record revealed no evidence the Ensure was given with meals from 07/28/15 through 08/06/15. During an interview with Clinical Informatics Nurse at 0910 on 08/07/15 she verified the above findings.


L. Review of the policy and procedure titled Dressing Changes revealed the following:

#2 WOUND
2.1 Obtain order for dressing or wound care...
2.10 Perform wound care according to physician's orders...
2.12 Document in Electronic Health Record...

#4 ULCER
41. Obtain order for dressing or ulcer care...
4.9 Perform ulcer care according to physician's orders.
4.10 Position patient for comfort. Remove gloves. Wash hands.
4.11 Document in Electronic Health Record...


M. Review of Patient #8's clinical record revealed she was admitted to the Facility on 07/28/15. Review of the physician's orders timed and dated 1432 on 07/28/15 revealed orders for daily dressing changes to hip. Review of the clinical record revealed no evidence dressing changes were performed on four (07/29/15 through 07/31/15 and 08/03/15) of nine (07/29/15 through 08/06/15) days. The above was verified by Clinical Informatics Nurse at 1335 on 08/07/15.


N. Review of Patient #9's clinical record revealed he was admitted to the Facility on 07/13/15. Review of the clinical record revealed on 07/19/15 at 0900 an abrasion to the coccyx was documented. At 1300 on the same day, a puncture wound on the right wrist was documented. Review of the clinical record revealed a consult to the Wound Care Nurse. Review of the Wound Care Nurse documentation dated 7/21/15 revealed a 3 cm long x 2 cm wide skin tear to the dorsal surface of the right arm/wrist with the base 50% (percent) pink and 50% dark purple. The ventral surface of the right arm/wrist was documented as 2.5 cm long x 2.5 cm wide with a 100% pink wound base. Orders dated 07/21/15 revealed to clean/irrigate/soak right wrist, dress with non-adherent dressing, apply cast padding and change every 12 hours through 08/06/15. Review of the clinical record revealed 14 of 15 days the dressing change was not performed every 12 hours as ordered. Review of the clinical record revealed an order dated 07/22/15 at 1400 to apply Silicone Foam dressing to coccyx every 72 hours and prn. Inspect skin every shift by gently peeling back dressing and then reapply. Review of the clinical record revealed the silicone dressing was not changed 07/25/15, 07/30/15, and 08/02/15. Review of the clinical record revealed no evidence of the wound sizes other than of the Wound Care Nurse for the wrist and coccyx. The above findings were verified by the Director of Quality at 1050 on 08/07/15.