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Based on medical record review, staff interview, and policy review the facility failed to ensure the state complaint hotline number and address were posted in the emergency room, failed to ensure informed consent was obtained for all patients, failed to ensure consent was obtained or court mandated treatment was instituted for a 72 hour psychiatric emergency patient, failed to ensure patients were offered information on advanced directives, and failed to ensure restraint use was incorporated into patient care plans. The cumulative effect of these sytemic practices resulted in the facility's inability to ensure patient's rights were observed.



Findings include:

The facility failed to ensure the state complaint hotline and address were posted in the emergency room. Please see A 118.

The facility failed to ensure informed consent was obtained for all patients and failed to ensure consent was obtained or court mandated treatment was instituted for a 72 hour psychiatric emergency patient. Please see A 131.

The facility failed to ensure patients were offered information on advanced directives. Please see A 132.

The facility failed to ensure restraints use was included in individual care plans. Please see A 166.

Based on observation and staff interview, the hospital failed to ensure all Emergency Department patients were informed of the State of Ohio's complaint hotline phone number and address. There were 50 patient medical records reviewed and the hospital census for the Willoughby, Ohio location at the time of the survey was 139 patients.

Findings include:

Observation in the patient waiting area of the Emergency Department located at 36000 Euclid Avenue, Willoughby, OH 44094 on 05/30/13 at 11:20 AM revealed the State of Ohio complaint hotline phone number and address were not posted anywhere in the Emergency Department patient waiting area. Staff C confirmed on 05/30/13 at 11:20 AM the lack of this posting in the ED waiting area.

Based on medical record review and staff interview, the facility failed to obtain a court order to keep an admitted patient after the 72 hour hold from an emergency admission application. This affected one out of four medical records (Patient 37) reviewed on the psychiatric unit.

Findings include:

Review of the medical record for Patient 37 completed on 05/30/13 revealed an admission date of 05/20/13 with diagnoses of psychosis and dementia. The patient was sent for an emergency admission from a long term nursing facility due to the patient harming two people within 48 hours. On the dates of 05/20/13, 05/22/13, 05/24/13, 05/27/13, and 05/29/13 attempts were made to contact the patient's daughter without success, it was passed on by the long term care facility that the patient's daughter was the power of attorney but was unable to provide documentation. No notation was documented of contact to the local court for a court order to detain the patient for treatment beyond the emergency admission application. A medical social worker note dated 05/29/13 revealed the intent for obtaining an emergency guardian. This was verified by Staff A on 05/30/13 at approximately 11:00 AM.

The facility was unable to provide a policy or procedure focused on emergency psychiatric admissions before the exit on 05/31/13.

Based on medical record review, policy review, and staff interview; the facility failed to offer information on advanced directives. This affected four out of 50 medical records reviewed (Patients 34, 38, 23, and 29). A total of 50 medical records were reviewed.

Findings include:

Review of the medical record for Patient 34 completed on 05/30/13 revealed an admission date of 05/28/13 to the rehabilitation unit and a diagnosis of hip fracture. The nursing admission assessment completed on 05/28/13 revealed the patient did not have advanced directives and was not offered information about making advanced directives. This was verified by Staff F on 05/30/13 at approximately 12:00 PM.

Review of the medical record for Patient 38 completed on 05/30/13 revealed an admission date of 05/24/13 to the rehabilitation unit and a diagnosis of hip fracture. The nursing admission assessment completed on 05/24/13 revealed the patient did not have advanced directives and was not offered information about making advanced directives. This was verified by Staff F on 05/30/13 at approximately 12:30 PM.

Review of the policy titled Patient's Rights and Responsibilities completed on 05/31/13 revealed patients with the mental capacity to understand information and to make voluntary choices may indicate, in advance, decisions that they have made regarding future health care through Advanced Directives.



22432

Patients 23 and 29 were both admitted to the facility on 05/29/13 for the completion of overnight sleep studies secondary to diagnoses of sleep apnea. Review of the medical records completed on 05/30/13 revealed the patients had signed blank forms entitled 'Patient Consent Forms'. The forms had multiple areas which required patient consent for such acknowledgments of receipt of the Patient Rights information, Patient Privacy Practices, and Personal Choices which included information on Advance Directives such as living wills, durable power of attorney for healthcare and whether or not the patient was an organ donor. Additionally, these consent forms included information and responsibilities regarding patients' personal belongings. These forms were unmarked with the exception of the patient and witness signatures who had signed and dated these blank forms.

Based on observation, medical record review, and staff interview; the facility failed to develop plans of care for two patients (Patients 1 and 31) for the use of restraints. This affected two of two patients reviewed with restraints. The facility census was 232 patients.

Findings include:

Patient 1 was admitted to the facility on 05/21/13 with diagnoses which included a change in mental status, sepsis, history of lung cancer. Review of the medical record completed on 05/28/13 revealed the patient had required mechanical ventilation for breathing. Additionally the patient required the use of bilateral soft wrist restraints secondary to his change in mental status and multiple attempts to remove medical equipment since his admission to the current date of 05/28/13.

Review of the Patient 1's plan of care revealed the facility had failed to develop a plan of care to direct the use of restraints. Observations on the morning of 05/28/13 revealed the patient remained in bilateral soft wrist restraints. Interview with Staff K on 05/28/13 at 3:49 PM verified this finding.

Patient 31 was admitted to the facility on 05/26/13 with diagnoses which included history of a stroke, aspiration pneumonia. Review of the medical record completed on 05/28/13 revealed the patient had required mechanical ventilation for breathing. Additionally the patient required the use of bilateral soft wrist restraints secondary to multiple attempts to remove his breathing tube since his admission to the current date of 05/28/13. Review of the patient's plan of care revealed the facility had failed to develop a restraint plan of care for this patient to direct facility nursing staff in the care and maintenance of this device. Observations on the morning of 05/29/13 revealed the patient remained in bilateral soft wrist restraints. Interview with Staff K on 05/28/13 at 3:48 PM verified this finding.

Interview with Staff D via telephone on 05/29/13 at 3:11 PM revealed the facility had not yet built a restraint plan of care into its computerized plan of care data base. Staff D verbalized staff nurses have the option to build or modify a patient's plan of care when they need it.

Interview with Staff K on 05/28/13 at 3:48 PM verified the facility failed to develop restraint plans of care for Patients 1 and 31.

Based on observation, staff interview, policy review, and medical record review; the facility failed to ensure staff followed hand hygiene practices regarding glove usage. This affected two of three dressing changes observed (Staff L and M and Patients 2 and 43). The facility failed to ensure wound care orders and a wound care consult were obtained in a timely fashion for Patient 2. A total of 50 medical records were reviewed.

Findings include:

On 05/29/13 at 11:00 AM, Staff L was observed to change the dressing to the coccyx of Patient 2. Staff L was observed to remove his/her gloves after removing the old dressing and to put on sterile gloves prior to applying the new dressing. Staff L was not observed to perform hand hygiene after removing his/her gloves and putting on new sterile gloves.

On 05/30/13 at 2:34 PM, Staff M was observed to change a dressing to Patient 43's fistula. Staff M removed his/her gloves after removing the old dressing and put on new sterile gloves. Staff M was not observed to perform hand hygiene with this glove change.

Staff B was interviewed on 05/30/13 at 2:53 PM. Staff B verified that Staff L and M had not performed hand hygiene between glove changes for either of these dressing changes and should have done so.

The Hand Hygiene policy was reviewed on 05/30/13. The policy stated that hand contamination may occur as the result of small undetectable holes in examination gloves and therefore hand hygiene must be done after removing gloves.


22432

Patient 2 was admitted to the facility from a long term care facility on 05/24/13 with diagnoses which included a stage III pressure sore to the coccyx and sacral areas (buttocks). Review of the medical record completed on 05/28/13 revealed the registered nurses admission clinical progress note dated 05/24/13 at 4:15 PM documented the patient had a stage III pressure ulcer which measured 2 centimeters in diameter on the coccyx (buttocks) and was 8 centimeters in length with a scant amount of red drainage. The note further documented a soiled dressing was removed and replaced with a mepilex border dressing (a non-medicated foam and silicone based dressing routinely stocked on nursing units). The patient's admission orders failed to document any wound care orders. Review of the medical record revealed the long term care facility where the patient resided had sent the patient's current medication and treatment regimens along with the patient to the hospital. The treatment for the patient's coccyx wound included a physician's order from 05/13/13 to cleanse the wound daily with normal sterile saline, apply an alginate with silver (specially medicated antimicrobial dressing) and to cover with a dry dressing.

Continued review of the patient's hospital medical record revealed the hospital had failed to obtain a physician's order for the continued care of the patient's pressure ulcer. Review of the physician's written orders dated 05/25/13 directed the facility to obtain a consult with a physician who specialized in skin care. The medical record failed to contain any physician consultation notes or wound nurse visit notes until the morning of 05/28/13 or an elapsed time of approximately 3 days after the physician's order was received.

Interview with Staff I on 05/29/13 at 9:15 PM verbalized it was the facility policy when patient's arrived with current physician's medication or treatment orders the facility would attempt to continue with those orders as long as these orders were still appropriate in the care of a patient. Additionally, Staff I verbalized it was the facility's policy that the patient is seen within 24 hours of the consult being ordered. Staff I verified it was an elapsed time of three days before the patient was seen by the wound care nurse on the morning of 05/28/13 and further verified the facility had failed to obtain any wound care orders for the patient's wound.

Based on medical record review and staff interview, the facility failed to ensure care plans were initiated and updated for all patients with all relevant needs addressed. This affected five of 50 medical records reviewed (Patients 43, 1, 31, 30, and 6).

Findings include:

The medical record for Patient 43 was reviewed on 05/30/13. The patient was admitted to the facility on 05/28/13 with the diagnosis for an infected fistula. The nursing assessment documented the fistula wound to the left upper arm was five centimeters by seven centimeters by two to three centimeters with yellow exudate. The medical record contained orders for a dressing change using one eighth strength Dakins solution. The care plan lacked any interventions for a wound or skin prevention as of 05/30/13 at 4:00 PM. This was verified by Staff B at the time of discovery.


22432

Patient 1 was admitted to the facility on 05/21/13 with diagnoses which included a change in mental status, sepsis, history of lung cancer. Review of the medical record completed on 05/28/13 revealed the patient had required mechanical ventilation for breathing. Additionally the patient required the use of bilateral soft wrist restraints secondary to his change in mental status and multiple attempts to remove medical equipment since his admission to the current date of 05/28/13. Review of the patient's record revealed the facility failed to develop a plan of care to include the use of restraints. Interview with Staff K on 05/28/13 at 3:49 PM verified this finding.

Patient 31 was admitted was admitted to the facility on 05/26/13 with diagnoses which included history of a stroke, aspiration pneumonia. Review of the medical record completed on 05/28/13 revealed the patient had required mechanical ventilation for breathing. Additionally the patient required the use of bilateral soft wrist restraints secondary to multiple attempts to remove medical equipment since his admission to the current date of 05/28/13. Review of the record revealed the plan of care failed to include the use of restraints. Additionally, the patient's dietary status had changed from receiving nourishment by mouth to a nothing by mouth with tube feed usage to meet the patient's nutritional needs. The facility failed to initiate a plan of care to address the patient's needs secondary to his tube feed. Interview with Staff K on 05/28/13 at 3:48 PM verified these findings.

Patient 30 was admitted to the facility on 05/29/13 with diagnoses which included coronary artery disease and new onset of chest pain with EKG (electrocardiogram) wave changes. Review of the medical record revealed the patient experienced chest pain rated as seven out of 10. Continued review of the medical record revealed the facility failed to initiate a plan of care to address the patients pain level. Interview with Staff K on 05/30/13 at 2:40 PM verified the facility had failed to initiate a plan of care or intervention realted to the patient's chest pain.






31159

The review of the medical record for Patient 6 was completed on 05/28/13 at 3:00 PM. Patient 6 was admitted to the hospital 05/26/13 with a diagnosis of melena (passing blood in the stool). Review of the medical record revealed Patient 6 was on two anticoagulant medications, Coumadin and aspirin (blood thinners), at the time of admission. The nursing care plan for Patient 6 lacked documentation of a plan or nursing interventions related to Patient 6's risk for bleeding.

In an interview with Staff D and Staff E on 05/30/13 at 3:15 PM, Staff D and Staff E confirmed that Patient 6's care plan was not specific to his/her primary needs and stated that the nurses on the patient care units do have the ability to create a care plan item independently if the item is not in the standard set.

Based on review of the electronic medical records suspension list and hospital medical record statistics form and staff interview, the hospital failed to ensure 204 medical records were completed within 30 days of patient discharge. The hospital census at the time of the survey was 232 patients.

Findings Include:

Review of the electronic medical records suspension list and hospital medical record statistics form were completed 05/29/13 at 2:00 PM. The suspension list revealed there were 204 total incomplete medical records greater than 30 days delinquent. The statistics form revealed for the time frame of April 2012 through April 2013, 15% of the closed medical records were greater than 30 days delinquent. This finding was confirmed with Staff A on 05/30/13 at 8:30 AM.

Based on review of the facility dietary department dishwasher logs, facility and corporate dietary staff interviews, manufacturer instructions, facility policy and procedure, the dietary director failed to ensure the dishwashing department followed safe sanitation procedures. This practice had the potential to affect an average of 420 daily trays that were served each day between the months of December 2012 and May 28, 2013 from the facility's west campus dietary department. The facility's west campus census at the time of survey (05/28/13) was 139.

Findings include:

Review of the facility's west campus dietary department dishwasher temperature logs completed on the afternoon of 05/29/13 revealed the facility's dishwasher frequently failed to come up to the manufacturer's required temperature for the hot water wash, or the final high temperature sanitizing rinse. The time frame under review was December 2012 through current date of 05/29/13.

Review of the manufacturers's printed directive for the facility's West campus dishwasher directed the hot water wash cycle of the machine must reach a minimum of 160 degrees Fahrenheit and the final hot water sanitizing rinse must reach 180 degrees Fahrenheit to adequately sanitize dishes and silverware used by patients. Review of the facility's undated and untitled staff directive directed facility staff that the West Campus dishwasher's wash temperature was 160 degrees or higher and the final rinse needed to be 180 degrees Fahrenheit. If the 180 degree final rinse water temperature was not reached staff was required to manually initiate the addition of a chemical sanitizing agent.

Review of the dishwasher temperature logs for the months of December 2012 for the breakfast and lunch meal service revealed eight days during the breakfast meal service in December 2012 the dishwasher failed to wash at the required 160 degrees Fahrenheit. Additionally, the machine failed to reach the required 180 degrees during the final heat sanitizing rinse on 27 days in December during the breakfast meal service. The logs revealed the lunch meal dishwasher temperature log revealed the dishwasher failed to wash at 160 degrees on 11 of 31 days in December 2012 and failed to reach the final sanitizing rinse of 180 degrees on 19 of the 31 days in December 2012. The facility was unable to provide the December 2012 dinner meal service dishwasher temperature logs.

Review of the January 2013 dishwasher temperature logs again documented the machine failed to come up to required temperatures for either the wash cycle or the final sanitizing rinse cycle on 16 days during the month of January, 2013 during the breakfast meal service, 19 days during the lunch meal service, and 19 days during the evening meal service. Review of the facility's Dishwashing Machine Corrective Action Log for the month of January 2013 only documented six time that corrective action for the low wash and rinse temperatures was initiated. The April 2013 dishwasher temperature logs documented three days during the breakfast meal service when the machine failed to meet required temperatures, eight days during the April lunch meal service, and 15 days during the evening meal service. Additionally, during the month of January 2013 during the lunch meal the dishwashing department staff failed to take any dishwasher temperatures for four consecutive days (01/18/13 through 01/21/13). The facility was unable to provide documentation that corrective action was taken when the dishwasher failed to meet required wash or sanitizing rinse cycle temperature requirements. The May 2013 dishwasher temperature logs documented eight days when the dishwasher failed to meet temperature requirements during the breakfast meal service, seven days during the lunch meal service and four days during the dinner meal service.

Review of the 12/02/12 Food Safety Training Attendance Roster revealed that dishwashing was discussed. January 2013 dietary huddle department notes documented the facility's dishwasher staff were all in-serviced on the temperature taking protocols and the need to document any corrective action taken when temperatures failed to reach required temperatures. All dishwashing staff verbalized understanding.

Review of the facility's dietary equipment maintenance company's work orders revealed the facility had frequent service calls for the facility's west campus dishwashing machine. The company made service calls to the facility for equipment complaints on 12/03/12, 12/20/12, 12/24/12, 01/15/13, 01/24/13, 02/06/13, 03/07/13, 03/26/13 and again on 05/22/13.

Interview with the Dietary Operations Manager (Staff H) on 05/29/13 at 4:10 P.M. verified the facility had ongoing concerns with the west campus' dishwashing department as well as the dishwashing machine. Staff H verbalized this dishwashing machine incurred multiple malfunctions and that the maintenance company had made numerous service calls to correct the problems without lasting success. Staff H further verbalized that dish department staff had all been in-serviced that when the dishwashing machine sanitizing rinse failed, the staff was required to manually activate a chemical sanitizing agent to ensure dishes and silverware were adequately washed and sanitized. The dish department staff was instructed to keep dishwashing machine temperature logs as well as the corresponding corrective action log and to document when the manual chemical booster was required to be used secondary to the machine's failure to reach required water temperatures. Staff was in-serviced that in addition to the corrective action log documentation the dishwashing staff was required to notify the facility's dietary management of the machine malfunction so the maintenance company could be contacted as well. Staff H verified at the time of interview that the dishwashing machine temperature logs consistently documented low wash and sanitizing rinse temperatures. Staff H further verified the facility was unable to provide documentation that corrective actions were followed when the dishwashing machine failed or that dietary management had been notified of the multiple failures of the west campus' dishwashing machine.

Interview on 05/31/13 at 2:27 P.M. with the facility's district manager of the food service company (Staff J) verified the dietary company had multiple ongoing concerns with the facility's west campus dishwashing machine.

Based on interview, record review, and observation, the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association for buildings 1-6, specifically, failed to maintain a two hour fire wall between the facility and a medical office building, failed to maintain the required construction type throughout building structure, failed to maintain the garbage chute damper door with construction having a fire resistance of at least two hours, failed to have a one hour fire resistance rating in the smoke barrier, failed to ensure areas enclosed with a one hour fire-rated barrier were free from penetrations, failed to ensure fire extinguishers were not obstructed from view, failed to ensure patient care areas were free from space heaters and failed to ensure compliance with NFPA 70 in general in regard to power strips. In addition the facility failed to ensure building construction type and height met the following building requirements for Type 1 construction, failed to ensure waiting areas in sprinkler buildings were open to corridor under conditions specified in Code, failed to ensure 30 minute smoke barriers are maintained, failed to ensure hazardous area doors had closing device and no penetrations in ceiling tiles, failed to ensure exit access was arranged so exits were accessible, failed to ensure fire protection of 1 hour for existing linen and trash chute, failed to ensure mobile linen or trash receptacles were located in a protected room, failed to ensure medical gas storage were protected in accordance with NFPA 99, failed to ensure smoke detectors were at least 36 inches from sources of air ventilation, failed to ensure doors had self closing device and sprinkler heads were maintained. The cumulative effect of these systemic practices resulted in the facility's inability to ensure that the facility was safe from fire.


Findings Include:

See A710.

Based on interview, record review, and observations, the hospital must meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients in the facility. The patient census was 18.

Findings include:

K11 Failed to maintain a two hour fire wall between the facility and a medical office building
K12 Failed to ensure that building construction type and height met the following building requirements for Type I construction
K17 Failed to ensure that in sprinkler building waiting areas and activity spaces were open to the corridor under certain conditions specified in the Code
K20 Failed to ensure door in stairwell-a vertical opening-was functional
K25 Failed to maintain 30 minute smoke barrier
K29 Failed to ensure door to hazard area had a self-closure
K38 Failed to ensure exit access were arranged so exits were accessible
K50 Failed to ensure fire drills were held at unexpected times under varying conditions at least quarterly on each shift
K62 Failed to ensure required automatic sprinkler system was continuously maintained
K64 Failed to ensure fire extinguishers were not obstructed from view
K70 Failed to ensure all patient care areas were free of space heaters
K71 Failed to ensure that any existing linen and trash chute, including pneumatic rubbish and linen systems sealed by fire resistive construction to prevent further use or was provided with a fire door assembly having a fire protection rating of 1 hour
K75 Failed to ensure that mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) were located in a room protected as a hazardous area when not attended
K76 Failed to ensure that medical gas storage and administration areas were protected in accordance with NFPA 99, Standards for Health Care Facilities
K130 Failed to ensure smoke detectors were at least 36 inches from a source of ventilation and ensure sprinkler heads are clean
K147 Failed to ensure compliance with NFPA 70 in general, and NFPA 70 110 3(b) and 400-7(b) in particular on the third floor

Based on medical record review, policy review, and staff interview; the facility failed to offer information on advanced directives. This affected four out of 50 medical records reviewed (Patients 34, 38, 23, and 29). A total of 50 medical records were reviewed.

Findings include:

Review of the medical record for Patient 34 completed on 05/30/13 revealed an admission date of 05/28/13 to the rehabilitation unit and a diagnosis of hip fracture. The nursing admission assessment completed on 05/28/13 revealed the patient did not have advanced directives and was not offered information about making advanced directives. This was verified by Staff F on 05/30/13 at approximately 12:00 PM.

Review of the medical record for Patient 38 completed on 05/30/13 revealed an admission date of 05/24/13 to the rehabilitation unit and a diagnosis of hip fracture. The nursing admission assessment completed on 05/24/13 revealed the patient did not have advanced directives and was not offered information about making advanced directives. This was verified by Staff F on 05/30/13 at approximately 12:30 PM.

Review of the policy titled Patient's Rights and Responsibilities completed on 05/31/13 revealed patients with the mental capacity to understand information and to make voluntary choices may indicate, in advance, decisions that they have made regarding future health care through Advanced Directives.



22432

Patients 23 and 29 were both admitted to the facility on 05/29/13 for the completion of overnight sleep studies secondary to diagnoses of sleep apnea. Review of the medical records completed on 05/30/13 revealed the patients had signed blank forms entitled 'Patient Consent Forms'. The forms had multiple areas which required patient consent for such acknowledgments of receipt of the Patient Rights information, Patient Privacy Practices, and Personal Choices which included information on Advance Directives such as living wills, durable power of attorney for healthcare and whether or not the patient was an organ donor. Additionally, these consent forms included information and responsibilities regarding patients' personal belongings. These forms were unmarked with the exception of the patient and witness signatures who had signed and dated these blank forms.

Based on observation, staff interview, policy review, and medical record review; the facility failed to ensure staff followed hand hygiene practices regarding glove usage. This affected two of three dressing changes observed (Staff L and M and Patients 2 and 43). The facility failed to ensure wound care orders and a wound care consult were obtained in a timely fashion for Patient 2. A total of 50 medical records were reviewed.

Findings include:

On 05/29/13 at 11:00 AM, Staff L was observed to change the dressing to the coccyx of Patient 2. Staff L was observed to remove his/her gloves after removing the old dressing and to put on sterile gloves prior to applying the new dressing. Staff L was not observed to perform hand hygiene after removing his/her gloves and putting on new sterile gloves.

On 05/30/13 at 2:34 PM, Staff M was observed to change a dressing to Patient 43's fistula. Staff M removed his/her gloves after removing the old dressing and put on new sterile gloves. Staff M was not observed to perform hand hygiene with this glove change.

Staff B was interviewed on 05/30/13 at 2:53 PM. Staff B verified that Staff L and M had not performed hand hygiene between glove changes for either of these dressing changes and should have done so.

The Hand Hygiene policy was reviewed on 05/30/13. The policy stated that hand contamination may occur as the result of small undetectable holes in examination gloves and therefore hand hygiene must be done after removing gloves.


22432

Patient 2 was admitted to the facility from a long term care facility on 05/24/13 with diagnoses which included a stage III pressure sore to the coccyx and sacral areas (buttocks). Review of the medical record completed on 05/28/13 revealed the registered nurses admission clinical progress note dated 05/24/13 at 4:15 PM documented the patient had a stage III pressure ulcer which measured 2 centimeters in diameter on the coccyx (buttocks) and was 8 centimeters in length with a scant amount of red drainage. The note further documented a soiled dressing was removed and replaced with a mepilex border dressing (a non-medicated foam and silicone based dressing routinely stocked on nursing units). The patient's admission orders failed to document any wound care orders. Review of the medical record revealed the long term care facility where the patient resided had sent the patient's current medication and treatment regimens along with the patient to the hospital. The treatment for the patient's coccyx wound included a physician's order from 05/13/13 to cleanse the wound daily with normal sterile saline, apply an alginate with silver (specially medicated antimicrobial dressing) and to cover with a dry dressing.

Continued review of the patient's hospital medical record revealed the hospital had failed to obtain a physician's order for the continued care of the patient's pressure ulcer. Review of the physician's written orders dated 05/25/13 directed the facility to obtain a consult with a physician who specialized in skin care. The medical record failed to contain any physician consultation notes or wound nurse visit notes until the morning of 05/28/13 or an elapsed time of approximately 3 days after the physician's order was received.

Interview with Staff I on 05/29/13 at 9:15 PM verbalized it was the facility policy when patient's arrived with current physician's medication or treatment orders the facility would attempt to continue with those orders as long as these orders were still appropriate in the care of a patient. Additionally, Staff I verbalized it was the facility's policy that the patient is seen within 24 hours of the consult being ordered. Staff I verified it was an elapsed time of three days before the patient was seen by the wound care nurse on the morning of 05/28/13 and further verified the facility had failed to obtain any wound care orders for the patient's wound.

Based on medical record review and staff interview, the facility failed to ensure care plans were initiated and updated for all patients with all relevant needs addressed. This affected five of 50 medical records reviewed (Patients 43, 1, 31, 30, and 6).

Findings include:

The medical record for Patient 43 was reviewed on 05/30/13. The patient was admitted to the facility on 05/28/13 with the diagnosis for an infected fistula. The nursing assessment documented the fistula wound to the left upper arm was five centimeters by seven centimeters by two to three centimeters with yellow exudate. The medical record contained orders for a dressing change using one eighth strength Dakins solution. The care plan lacked any interventions for a wound or skin prevention as of 05/30/13 at 4:00 PM. This was verified by Staff B at the time of discovery.


22432

Patient 1 was admitted to the facility on 05/21/13 with diagnoses which included a change in mental status, sepsis, history of lung cancer. Review of the medical record completed on 05/28/13 revealed the patient had required mechanical ventilation for breathing. Additionally the patient required the use of bilateral soft wrist restraints secondary to his change in mental status and multiple attempts to remove medical equipment since his admission to the current date of 05/28/13. Review of the patient's record revealed the facility failed to develop a plan of care to include the use of restraints. Interview with Staff K on 05/28/13 at 3:49 PM verified this finding.

Patient 31 was admitted was admitted to the facility on 05/26/13 with diagnoses which included history of a stroke, aspiration pneumonia. Review of the medical record completed on 05/28/13 revealed the patient had required mechanical ventilation for breathing. Additionally the patient required the use of bilateral soft wrist restraints secondary to multiple attempts to remove medical equipment since his admission to the current date of 05/28/13. Review of the record revealed the plan of care failed to include the use of restraints. Additionally, the patient's dietary status had changed from receiving nourishment by mouth to a nothing by mouth with tube feed usage to meet the patient's nutritional needs. The facility failed to initiate a plan of care to address the patient's needs secondary to his tube feed. Interview with Staff K on 05/28/13 at 3:48 PM verified these findings.

Patient 30 was admitted to the facility on 05/29/13 with diagnoses which included coronary artery disease and new onset of chest pain with EKG (electrocardiogram) wave changes. Review of the medical record revealed the patient experienced chest pain rated as seven out of 10. Continued review of the medical record revealed the facility failed to initiate a plan of care to address the patients pain level. Interview with Staff K on 05/30/13 at 2:40 PM verified the facility had failed to initiate a plan of care or intervention realted to the patient's chest pain.






31159

The review of the medical record for Patient 6 was completed on 05/28/13 at 3:00 PM. Patient 6 was admitted to the hospital 05/26/13 with a diagnosis of melena (passing blood in the stool). Review of the medical record revealed Patient 6 was on two anticoagulant medications, Coumadin and aspirin (blood thinners), at the time of admission. The nursing care plan for Patient 6 lacked documentation of a plan or nursing interventions related to Patient 6's risk for bleeding.

In an interview with Staff D and Staff E on 05/30/13 at 3:15 PM, Staff D and Staff E confirmed that Patient 6's care plan was not specific to his/her primary needs and stated that the nurses on the patient care units do have the ability to create a care plan item independently if the item is not in the standard set.