HospitalInspections.org

Based on observations and interviews the hospital failed to ensure the patients in the psychiatric hospital were provided care in a safe setting as evidenced by the hospital having 4 beds with metal bases with removable springs and small interlocking metal pieces and 18 beds with metal bases with metal slats that present a ligature risk. Findings


Review of the hospital policy on Suicidal Risk/Protective Factors Assessment and Precautions, Category I- Patient is in imminent danger of implementing suicide 3) Nursing Interventions c) daily room searches, as indicated, and placement in bed without any risk of ligature such as "wooden box bed"...

Observations were conducted on 8/5/15 at 9:45 a.m. of 4 patient beds with metal bases with removable springs and small interlocking metal pieces and 18 beds with metal bases with metal slats that present a ligature risk.

An interview was conducted with S4Environmental Director on 8/5/15 at 9:45 a.m. He reported the beds with metal springs could be removed from the metal base of the beds and the springs had sharp edges.

An interview was conducted with S1Administrator on 8/6/15 at 10:00 a.m. She reported at the other hospitals the corporation owns, the hospitals has wooden box beds. Patients are placed in the "wooden box beds" if they are assessed as a high suicide risk. S1Administrator reported this hospital does not have wooden box beds. S1Administrator further reported the hospital's policies refer to all the hospitals the corporation owns.

Based on policy review, record review and interview, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by failing to document assessments of a pressure ulcer for 1 (#5) of 5 (#1 - #5) patients sampled.

Findings:

Review of the hospital policy titled Wound Assessment and Documentation, policy No. NS-025 revealed in part:
6. Measure wound (area and depth)
7. Assess wound edges, undermining, and tunneling.
8. Assess wound bed moisture.
9. Assess amount of devitalized tissue.
10. Assess amount of granulation tissue.
11. Assess amount of epithelium.
12. Assess the surrounding skin for color and condition.
14. Document and date all information, position of the patient when measurements (photographs) were obtained as well as method of measurement used in the medical record.

Review of the medical record for Patient #5 revealed he was a current patient admitted on 7/31/15 with diagnosis which included a Stage II pressure Ulcer on his buttocks.

Review of the medical record revealed an order on 8/1/15 for Boudreaux ' s Butt Paste to perineal excoriation daily and PRN (as needed) and Duoderm to stage II decubitus to buttocks. Change every 3 days and PRN.

Review of the care plan for Patient #5 revealed the plan for the Stage II pressure sore to inner buttocks was listed as: Assess skin integument each shift, assess and document status of wound to inner buttock each shift (description, location, measurement, surrounding tissue, drainage, odor, etc.), monitor and record nutrition and hydration intake each shift.

Review of the medical record for Patient #5 revealed no documented evidence of wound assessments to the Stage II pressure ulcer to the buttocks.

In an interview on 8/6/15 at 1:10 p.m. with S2DON, he verified Patient #5 did not have any documented descriptions of his pressure ulcer to the buttocks including depth, size, color, odor, drainage or wound edges. S2DON said the only documentation of the wound was on 8/4/15 when the nurse charted the dressing had been changed but did not describe the wound. S2DON verified the wound should have had a descriptive documentation in the medical record.

Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient. This deficient practice is evidenced by failing to include reverse isolation as an identified problem for 1 (#5) of 5 (#1 - #5) patients' care plans reviewed
Findings:
Review of the hospital Policy Titled Provision of Care, Treatment and Services revealed in part:
1. Every patient shall have an individualized comprehensive plan of care.
4. Every patient's plan of care shall identify patient goals and associated objectives and interventions necessary to meet the identified goals.
6. Goals and objectives will be reevaluated and, as necessary, revised based on changes in the patient ' s condition, needs and response to care, treatment and services. Care, treatment and services for each patient is based on the plan of care, treatment or services.

Review of the medical record for Patient #5 revealed he was a current patient admitted on 7/31/15 with diagnosis which included basal carcinoma of the scalp and multiple myeloma. He also was diagnosed with pancytopenia (a reduction in the number of white and red blood cells).

Review of the medical record for Patient #5 revealed an order dated 8/1/15 at 6:15 p.m. to ask the medical doctor to assess Patient #5 for the need for reverse isolation because of a decreased white blood cell count on 7/20/15. Further review revealed an order dated 8/3/15 at 6:00 p.m. to consult infection control for a policy for reverse isolation.

Review of the care plan on 8/6/15 revealed no problem had been identified for Patient #5 requiring reverse isolation for pancytopenia.

In an interview on 8/6/15 at 10:48 a.m. with S2DON, he said reverse isolation was protecting the patient from potential infections from the staff. S2DON said Patient #5 should have been care planned for being placed in reverse isolation.

Based on record review, observation and interview, the hospital failed to ensure the infection control officer developed and implemented a system to control infections. This deficient practice is evidenced by failing to institute reverse isolation until 5 days after admission for a patient susceptible to infection, failing to ensure staff was knowledgeable about reverse isolation precautions and failing to devise a policy for reverse isolation for 1 (#5) of 1 patients on isolation precautions.

Findings:

Review of the isolation policy provided by the hospital revealed no guidance for reverse isolation.

Review of the medical record for Patient #5 revealed he was a current patient admitted on 7/31/15 with diagnosis which included basal carcinoma of the scalp and multiple myeloma. He also was diagnosed with pancytopenia (a reduction in the number of white and red blood cells).

Review of the medical record for Patient #5 revealed an order dated 8/1/15 at 6:15 p.m. to ask the medical doctor to assess Patient #5 for the need for reverse isolation because of a decreased white blood cell count on 7/20/15. Further review revealed an order dated 8/3/15 at 6:00 p.m. to consult infection control for a policy for reverse isolation.

In an observation on 8/5/15 at 2:00 p.m., Patient #5 did not have any signage on his door indicating any type of isolation precautions. Patient #5 was also located in a double occupancy room. In an observation on 8/6/15 at 9:30 a.m., Patient #5 had been moved to a single occupancy room and had a sign on his door for reverse isolation.

In an observation on 8/6/15 at 11:30 a.m., Patient #5 was observed in the dining room eating at the table with Patient #R3 and Patient #R4.

In an interview on 8/6/15 at 9:40 a.m. with S7RN, she said Patient #5 was on reverse isolation because he had a low white blood cell count and was at risk for an infection. She said he was not put on reverse isolation until the evening of 8/5/15. S7RN said reverse isolation was wearing a mask and gloves when entering the patient ' s room.

In an interview on 8/6/15 at 10:48 a.m. with S2DON, he said reverse isolation was protecting the patient from potential infections from the staff. S2DON said the staff should have worn a mask, gown and gloves when entering the patient ' s room. S2DON said if Patient #5 came out of the room, he was to wear a mask, gown and gloves. S2DON verified the policy for isolation did not address reverse isolation but should have. He said he called the medical doctor on 8/4/15 but did not clarify an order for Patient #5 for reverse isolation. He said it was an oversight to not put him on precautions when he was admitted on 7/31/15 with a low white blood cell count.

In an interview on 8/6/15 at 11:09 a.m. with S8RN, she said she was the infection control nurse at the hospital. S8RN said reverse isolation was used to protect the patient if the patient had a low white blood cell count. S8RN said she the patient should have been in a private room and he should have worn a mask when in public places outside of the room. S8RN said staff had to wear a mask when entering Patient #5 ' s room but did not have to wear gloves or a gown. S8RN also said Patient #5 was not started on reverse isolation until the 8/5/15 but should have been started on 8/1/15.