HospitalInspections.org

Based on medical record review, document review and interview, in one (1) of 24 medical records reviewed, it was determined the medical staff failed to monitor, evaluate and treat a patient's low albumin level. (Patient #1).

Findings include:

Review of the medical record for Patient #1 identified the following: an eighty-two year old patient was admitted to the facility on 5/24/16 with a Stage II Sacral Decubiti ulcer (pressure ulcer). The admitting diagnosis was Gallstones with a history of poor food intake and severe malnutrition related to chronic disease. The patient's albumin level was 3.0 on 5/24/16 (normal level is 3.5 - 4.9 G/DL) and albumin levels were noted in the medical record as follows:
5/25/16 albumin level - 2.5
5/27/16 albumin level - 2.2
6/2/16 albumin level - 1.9
6/4/16 albumin level - 1.7
6/11/16 albumin level - 1.7

There were no subsequent tests for albumin levels during the remainder of the patient's hospitalization.
There was no documented treatment plan for the patient's decreasing albumin level.

On 6/2/16, the wound care nurse documented there was a right parasacral unstageable pressure ulcer, a Stage II pressure ulcer on the right posterior superior iliac spine and moisture associated skin damage on the sacrum and buttocks.
On 6/22/16 the sacral pressure ulcer had increased to Stage IV and there was a Stage II pressure ulcer on the inferior aspect of the right buttock. The patient was discharged on 6/24/16 with a Stage IV sacral pressure ulcer and a Stage II pressure ulcer on the inferior aspect of the right buttock.

Review of the policy titled "Prevention and Management of Pressure Ulcers," last reviewed in 2016, states: it is important that low albumin level of patients with decubiti ulcers must be monitored and treated to promote healing.

These findings were shared with Staff A, Associate Director of Nursing, wound Ostomy & Continence, on 7/20/17 at 3:05 PM.

Based on medical record review, document review and interview, in one (1) of 25 medical records reviewed, it was determined (a) the nursing staff failed to reassess a patient's mental status in a timely after it was determined the patient was lethargic and (b) failed to notify a healthcare provider of a change in the patient's condition (Patient #1).

Findings include:

Review of the medical record for Patient #1 identified the following: an eighty-two year old patient was admitted to the facility on 5/24/16 with a diagnosis of Gallstones with abdominal pain and Urinary Tract Infection. The patient's medical history included Asthma, a stroke, Hypertension, an extensive ventral (abdominal) hernia, Hypothyroidism and a Stage II Sacral Decubiti (wound on the sacrum).

A registered nurse documented at 8:44 PM on 5/28/16 that the patient was alert to person, her language was clear, she was able to swallow solids and liquids without difficulty and her Glasgow Coma Scale (GCS- a neurological assessment to record the consciousness of a person) was 15 ( On a score ranged between 3 and 15).
At 9:51 PM on 5/30/16, Staff B, registered nurse documented the patient was lethargic (an abnormal state of drowsiness), follows commands, chokes on solids, chest rhonchi was present and the GCS had decreased to 13.

There was no nursing documentation of a reassessment of the patient's lethargic condition until approximately 12 hours later. There was no documentation to indicate that a nurse informed a physician of the change in the patient's mental status.

A CT-Scan of the head was ordered and completed on 5/31/16 at 7:34 AM. Staff C, RN documented at 12:11 PM on 5/31/16 that she "received the patient at 7:00 AM from CT-Scan of the head. Patient lethargic. Pupils dilated."

On 5/31/16 at 9:14 AM, the physician documented that the "patient was found obtunded (greatly reduced level of consciousness, stupor) that morning, breathing agonally (difficult breathing) with significant change in mental status from over the weekend, not responding to sternal rub." A blood gas test showed severe respiratory acidosis, Narcan medication (indicated for the complete or partial reversal of opioid depression, including respiratory depression) was administered without response and a decision was made to intubate the patient. The patient was intubated on 5/31/16 at 9:25 AM.

A neurological assessment of the patient was then documented by the RN at 10:48 AM on 5/31/16.

During interview on 7/19/17 at approximately 2:00 PM, Staff C stated that on 5/31/16 that morning, she assessed the patient's pupil response and noted that it was sluggish and that she administered oxygen to the patient, however, she confirmed that she did not document these interventions in the medical record.

The policy titled "Nursing Documentation," last revised 4/17 states "reassessment, using the Charting by Exception model must be documented when there is a change in the patient's current condition, care needs and/or the plan for discharge." The policy also states "notification of the healthcare provider regarding a significant change in patient condition or related to an important patient/family inquiry must be entered in the patient record including the name of the person notified and the time of notification."



Review of the medication administration record revealed that Staff B, a registered nurse administered Narcan intravenously at 8:39 AM on 5/31/16. The standard of practice for administering Narcan is that the patient's lethargy and mental state should be assessed before and after the medication is given but there was no nursing documentation that patient's mental status was assessed prior to the administration of the drug nor was there a timely nursing assessment after the drug was given.

A nurse practitioner documented at 10:24 AM on 5/31/16 that a nurse called her for a "sepsis trigger" (suspected infection) and she arrived at the bedside "to find patient unarousable (cannot awaken) to tactile or verbal stimuli. Shallow respirations, primary team at bedside." Two liters of normal saline and 2 antibiotics were given for concern for possible sepsis.

The nursing staff did not document the time that the sepsis call was triggered.

This finding was shared with the Senior Director of Quality Management & Performance Improvement on 7/20/17 at 3:00 PM.

Based on medical record review, document review and interview, in 1 (one) of 24 medical records reviewed, it was determined the nursing staff did not formulate a care plan to meet the changing needs of the patient. (Patient #1).

Findings include:

Review of medical record for Patient #1 identified the following: At 9:51 PM on 5/30/16, Staff B, registered nurse documented the patient was lethargic (an abnormal state of drowsiness), follows commands, chokes on solids, chest rhonchi was present and the GCS had decreased to 13. (GCS- a neurological assessment to record the consciousness of a person. The assessment score ranged between 3 and 15).

On 5/31/16 at 9:14 AM, a physician documented that the "patient was found obtunded (greatly reduced level of consciousness, stupor) that morning, breathing agonally (abnormal breathing) with significant change in mental status from over the weekend, not responding to sternal rub. Blood gas testing showed severe respiratory acidosis; treatment was initiated and the patient was intubated at 9:25 AM on 5/31/16.

There was no documentation that the nursing staff formulated a care plan to address these changes in the patient's condition which were identified at 9:51 PM on 5/30/16.

The policy titled "Nursing Documentation," revised 4/17 revealed when there is a change in patient's condition nursing care plan documentation is required.

This finding was shared with the Senior Director of Quality Management & Performance Improvement on 7/20/17 at 3:00 PM.