HospitalInspections.org

Based on a review of medical records, hospital policy and procedures and interview with administrative staff it was determined the hospital failed to:

1. Revise the treatment plans.
2. Update the treatment plans to add or change interventions when a change occurs in the patient's status.
3. Assure the goals are based upon the patient's assessment and are realistic, relevant, measurable and specific to the individual patient.
4. Include discharge planning.

This had the potential to affect all patients served by the hospital and did affect Medical Record numbers 16 and 18 two of three active patients observed and reviewed.

Findings include:

Policy: Multidisciplinary Treatment Planning
Revised: April 26, 2010

Policy: It is the policy of the Senior Care Unit that each patient will have a multi-disciplinary treatment plan (MDTP) based on assessments conducted by all disciplines. This plan will be used to direct the provision of care to patients and the treatment to each patient will be consistent among disciplines.

Procedure:
2.0- Within 24 hours of admission the history and physical will be completed, and within 60 hours the psychiatric evaluation will be completed. At this time an initial treatment plan will be documented in the patient's medical record by the attending physician.
6.0- Guidelines for treatment plans:
6.1- The treatment plan will identify problems and strengths/resources.
6.2- The treatment plan will identify goals of treatment.
6.2.1- Goals are based upon the assessments and are realistic, relevant, measurable, specific to the individual patient and consistent with the therapy prescribed by the medical practitioner.
6.2.2- Goals identify what the patient will accomplish in treatment.
6.2.3- Each treatment goal will be dated when it is identified.
7.0- Within 7 days of admission all disciplines, under the coordination of the attending physician will, at the Multidisciplinary Treatment Planning meeting, develop the Master Treatment Plan. This includes identification of patient strengths and assets, a comprehensive problem list, discharge planning and program and treatment interventions.
7.4- Interventions will be measurable and specific to the types of patients involved.
8.0- The treatment plan will be formally reviewed in the Multidisciplinary Treatment Planning meeting at 7-day intervals or more often if indicated.
9.1- When a change occurs in the patient's status, the treatment plan will be updated to provide needed interventions.

The surveyor was provided copies of new forms to be used by the staff in developing the Multidisciplinary Treatment Plan 11/16/10 at 12:30 PM. The surveyor asked for a policy and procedure and was informed by the director of the Senior Care unit that the policy had not changed from what the surveyor received in September 2010, while onsite conducting a complaint investigation.

Medical Record Findings:

1. Medical Record (MR) # 18 was admitted to the Senior Care unit 10/25/10 with a diagnosis of Dementia with behavioral disturbances, possible dementia with psychosis.

The Interdisciplinary Treatment Plan in the medical record was dated 11/1/10. The plan was signed by the Psychiatrist, Social Worker, Activity Director, the Program Director and the RN who completed the admission assessment.

The diagnosis on the form included:
Axis I: Dementia with behavioral disturbance
Axis II: None
Axis III: CHF (congestive heart failure), Pacemaker, Pulmonary Dysfunction and Alzheimer's disease.
Axis IV: Severe
Axis V: 15-20.

The Master problem list:
1. Alzheimer's with behavioral disturbance- physically aggressive, noncompliant with medications, belligerent, requiring 1:1 observation
2. Fall
3. Skin integrity

The Master treatment plan review dated 11/1/10 listed the following problems and goals:
Problem 1- Behavior progress toward short-term goal unchanged. Pt. (patient) with improved behavior, current plan effective will continue through 11/8/10.
Problem 2- Fall progress toward short-term goal unchanged. Pt. with no fall and no injury, current plan effective will continue through 11/8/10.
Problem 3- Skin progress toward short-term goal was not marked. Pt. with no new skin issues current plan effective will continue through 11/8/10.

The date of the initial treatment was 11/1/10,the review of the plan was conducted 11/1/10 with the goals as unchanged.

The Master treatment plan review dated 11/8/10 listed the following problems and goals:
Problem 1- Behavior progress toward short-term goal was not marked. Pt. with improved behavior will continue current plan effective through 11/15/10.
Problem 2- Fall progress toward short-term goal was not marked. Pt. had no falls. Will continue current plan through 11/15/10.
Problem 3- Skin progress toward short-term goal was not marked. Pt. had no new skin issues will continue current plan through 11/15/10.

The Master treatment plan review dated 11/15/10 listed the following problems and goals:
Problem 1- Behavior progress toward short-term goal was unchanged. Pt. with minimal improvement current plan effective. Pt approaching readiness for discharge, will continue current plan.
Problem 2- Fall progress toward short-term goal was unchanged. Pt. with no falls. With no injuries. Current plan effective will continue with current plan until discharge or 11/22/10.
Problem no number listed-Progress toward short-term goal was not marked. Pt. with no fall or injury. Current plan effective, will continue plan through 11/22/10 or discharge.

The weekly reviews failed to document changes as they were occurring with the patient and failed to add or update interventions to address the patient's needs.

A review of the medical record identified the patient had weight loss. On admission 10/25/10 the weight was 238 pounds. The patient was consuming 75 to 100 % of his meals until 10/30/10 when he had a marked decline in the consumption of his meals.
On 10/30/10- Breakfast 50%, Lunch- 0%, Dinner- 40%, Snack-0%.
On 10/31/10- Breakfast 0%, Lunch-100%, Dinner- 5%, Snack-0
On 11/2/10- Breakfast 75%, Lunch- 30%,Dinner- 75%, Snack-10%.
On 11/3/10- Breakfast 5%, Lunch-100%, Dinner-100%, Snack-100%.
On 11/4/10- Breakfast 80%, Lunch- 0%, Dinner- 100%,Snack-100%.
On 11/5/10- Breakfast 100%, Lunch- 50%,Dinner- 100%,Snack-0%.
On 11/6/10- Breakfast 100%, Lunch- 20%,Dinner- 10%,Snack-0%.
On 11/7/10- Breakfast 100%, Lunch- 25%,Dinner- 0%,Snack-100%.
On 11/9/10- Breakfast 100%, Lunch- 75%, Dinner- 0%,Snack-100%.
On 11/10/10- Breakfast 0%, Lunch-100%,Dinner- 0%,Snack-0%.
On 11/11/10- Breakfast 25%, Lunch- 50%,Dinner- 0%,Snack-0%.
On 11/12/10- Breakfast 10%, Lunch- 20%,Dinner- 0%,Snack-100%.
On 11/13/10- Breakfast 100%, Lunch- 25%,Dinner- 25%,Snack-100%.
On 11/14/10- Breakfast 25%, Lunch- 0%,Dinner- 0%,Snack-100%.
On 11/15/10- Breakfast 50%, Lunch- 40%,Dinner- 0%,Snack-100%.
On 11/16/10- Breakfast 0%, Lunch- 100%,Dinner- 25%,Snack-100%.
The patient ' s weight on 11/14/10 was 227.5 pounds, a 10.5 pound weight loss in 20 days.


The physician documented in his progress notes, " Pt. experiencing poor appetite and decreased intake will ask for dietary consult and check lab."

On 11/3/10 in the communication notes the dietitian documented," Physician requested dietary consult, Pt's pre-albumin is 25, indicates normal nutrition. Pt's wt (weight) is within normal range for height. Wt. has remained steady since admit. Calorie needs approximately 2000 per day. "
There was no other follow up documented by the dietitian in the medical record.

On 11/11/10 the physician wrote an order to change the diet to mechanical soft diet if better tolerated.
The progress note from the physician dated 11/14/10 documented, " Pt with 10 pound weight loss but changes on chest x-ray consistent with? infiltrate/CHF ... PTE (pulmonary thromboembolus) more likely explanation little to do other that Coumadin and support hose."

On 11/15/10 the physician ordered daily weights.

This problem was not addressed in the weekly team meetings to update the treatment plan, goals and interventions.

A review of the medical record identified the patient had scraped the left side of his back on Geri-chair trying to get up 11/8/10 as documented by the nurse in her assessment.
The nurse documentation on 11/9/10 did not mention a scrape to his back but did document," Skin tear left arm, Tegaderm to skin tear change every 72 hours."
There was no order in the medical record for the use of Tegaderm.

The nurse documentation on 11/10/10 did not mention a scrape to the back but did list Tegaderm under the wound care section.

The nurse documentation on 11/11/10 did not mention a scrape to the back, skin tear or use of Tegaderm but did document under wound care,"Yeast on groin area."
The nurse documentation on 11/12/10 documented,"No skin breakdown noted."

In a response to written questions provided to administrative staff 11/17/10, Employee Identifier # 1, the Chief Operating Officer of Sunrise confirmed 11/18/10 at 8:30 AM, there was no order for the Tegaderm. EI # 1, stated that the scrape was not treated as it was not a problem.

The social worker activity documentation indicated a problem with the current spouse and her behaviors. The spouse had removed the patient from a nursing home prior to him being admitted to the Senior Care Unit. An order was written by the physician 11/3/10,"Wife not allowed to visit until input from DHR (Department of Human Resources)." The last entry in the social work section was dated 11/8/10. It documented,"Called and left message with ... at Jackson County DHR to return my call. Trying to obtain temporary guardianship for patient."

In a response to written questions provided to administrative staff 11/17/10, EI # 1, provided the surveyor with a late entry note 11/18/10 at 8:10 AM. The late entry note was written 11/17/10 for 11/16/10 and documented, " Called and left message with ...to return my call ASAP (as soon as possible), attempting to set up guardianship hearing prior to discharge. Pt's son aware of this at this time..."
This entry was documented 8 days after the last entry.

There was no indication this problem had been addressed or changes made to meet the patient's needs related to discharge planning.

3. MR # 16 was admitted to the Senior Care unit 11/8/10 with a diagnosis of Dementia with behavioral disturbances and dementia with psychosis.

The Initial Interdisciplinary Treatment Plan in the medical record was dated 11/15/10. The plan was signed on 11/8/10 by the Social Worker, Activity Director, the Program Director and the RN who completed the admission assessment. The psychiatrist failed to sign the form.

The diagnosis on the form included:
Axis I: Dementia
Axis II: None
Axis III: Osteoarthritis,Hypothyroidism, Hypertension and Hyperlipidemia.
Axis IV: Behavior issues and health problems
Axis V: 35.

The Master problem list:
1. Infection
2. Post Fall
3. Disruptive behavior
4. Fall risk
5. Cognitive improvement

The master treatment plan review was conducted 11/15/10 and failed to change or address new patient care problems developed. The patient had experienced weight loss and wound integrity issues since 11/8/10.

The Master treatment plan review dated 11/15/10 listed the following problems and goals:
Problem 1- Infection progress toward short-term goal was marked unchanged. Tx (treatment) plan effective. Will continue all interventions skin breakdown actually healing. The problem number one, form dated 11/14/10, documented, " Urinary tract infection- admitted with orders for Septra." This problem was not related to skin breakdown. The short term goal was dated 11/14/10 with a target date of 11/15/10.
Problem 2- Fall- treatment plan effective will continue all interventions. Progress toward short-term goal was marked unchanged.
Problem 3- Disruptive behavior progress toward short-term goal was marked unchanged. Treatment plan effective will continue all interventions.
Problem 4- Fall risk,treatment plan effective will continue all interventions. The short-term goal was not marked.
Problem 5- Cognitive impairment Treatment plan effective for symptoms of cognitive impairment will continue all intervention. Progress toward short-term goal was marked unchanged.

The patient's weight on 11/8/10, admission, was 158.5 pounds and 11/14/10, 6 days later was 150 pounds.

On 11/10/10- Breakfast 0%, Lunch- 100%,Dinner- 40%,Snack-0%.
On 11/11/10- Breakfast 40%, Lunch- 0%,Dinner- 50%,Snack-100%.
On 11/12/10- Breakfast 25%, Lunch- 20%,Dinner- 100%,Snack-100%.
On 11/13/10- Breakfast 100%, Lunch- 25%,Dinner- 5%,Snack-0%.
On 11/14/10- Breakfast 85%, Lunch- 70%,Dinner- 0%, Snack-100%.
On 11/15/10- Breakfast 40%, Lunch- 30%,Dinner- 0%,Snack-10%.
On 11/16/10- Breakfast 15%, Lunch- 25%,Dinner- 5%,Snack-0%.

A dietitian note documented 11/10/10, " Received consult request for 77 year old female on Senior Care Unit due to lactose intolerance. Pt. also has pre-albumin of 15, indicating mild malnutrition. Pt's BMI is 29 indicating over weight for height. Calorie needs 1275/day with 57 G (gram) protein. Pt would need to consume approximately 75% of all meals in order to maintain present weight. Pt may need supplement if intake is not appropriate."

A physician's order dated 11/14/10 documented, "May change to mechanical soft diet if better tolerated."

There was no change made to the master treatment plan, no new interventions put in place for the weight loss and even though the dietitian documented a supplement might be needed if intake is in-appropriate no one offered any supplements.

On 11/16/10 at 11:00 AM the surveyor observed the patient sitting in a reclined chair against the wall, the patient was exhibiting tremors in all extremities. A review of the medical record revealed the following medications were administered since admission:
11/9/10 Haldol 5 mg (milligrams) IM (intramuscular) for agitation at 2020. PRN Ambien was also given for insomnia.
11/10/10 Haldol 5 mg IM anxiety/ restless 2130.
11/12/10 Haldol 5 mg IM for agitation 2043.
11/13/10 Cogentin 1 mg given by mouth per MD (medical doctor) order at 1130.
11/15/10 Ambien 5 mg given for insomnia 2400.
11/15/10 Cogentin 1 mg IM per MD for EPS (Extrapyramidal) 1550. Benadryl 50 mg by mouth 1750.

The physician's progress note dated 11/15/10 at 1040 documented, " Pt is more lethargic this AM. She has had Ambien last night and slept. She has had some tremors which responded to low dose Cogentin... She remains delusional and paranoid."

The physician first ordered Cogentin 11/13/10 at 1 mg by mouth twice a day. On 11/15/10 an order was written to decrease Risperdal to 1 mg twice a day at 1535. A second order written 11/15/10 at 1740 was for Benadryl 50 mg when available. A third order written 11/15/10 at 1750 was to discontinue Cogentin PRN, hold Risperdal and start Cogentin 1 mg every 4 hours as needed IM. Continue scheduled Cogentin.

The first entry in the documentation of the nurse for 11/16/10 documented, " Pt lying in bed with eyes closed... visible EPS, pt incoherent..."
On 11/16/10 the patient's condition declined, at 1405 the Rapid Response team was called after patient was returned to her room from the large group room. The nurses documentation, " Pt appears to have tonic clonic seizure. MD notified..."

The Rapid Response team documentation,"Jerking type motion incoherent O2 saturation 88 % on room air." Dr... notified 1415 patient condition with an order received to administer Benadryl 50 mg by mouth.

The physician visited the patient at 1550 and discontinued the Allegra, Cogentin and Risperdal.

The physician's progress note for 11/16/10 at 1545 documented, " Pt is awake but delirious. She is unable to speak coherently... She has had jerking motion. She has no incontinence. She has not been coherent today... She received a PRN of Benadryl without much change today nor last night..."

In written questions to the Administrative staff 11/17/10 the surveyor asked how often the Registered Nurses assess the patient. EI # 1 responded 11/18/10 at 7:50 AM that the chart held 4 notes from the nurse and that the patient was under direct observation of the Mental Health worker and the Activity Director in the group room until the nurse called the doctor.

There was no changes made to the master treatment plan on 11/15/10 even though the patient was exhibiting EPS symptoms and the weight loss was never addressed.

Based on review of medical records and interview the facility staff failed to follow orders for wound care provided to patients and failed to assure a physician's order was obtained prior to providing wound care in 3 of 5 patients with wounds. This affected Medical Record (MR) #s 17, 18 and 20.

Findings include:

1. Medical Record (MR) # 20 was admitted on 1/6/10 with the diagnosis of Altered Mental Status and Atrial Fibrillation.

According to the documents in the record, the patient developed a blister to the right heel on 1/9/10. A Stage II Wound Care Algorithm sheet was in the physician's order section of the record. The physician had signed this as an order. The sheet contained the following information: If a blister, 1. Place patient on Air Mattress or overlay. 2. Leave blister open to air. 3. Keep clean and dry. 4. No direct pressure on blister.

A review of the nurse's documentation dated 1/10/10, 1/11/10 and 1/12/10 revealed the blister on the heel was covered with a duoderm.


2. MR # 18 was admitted to the Senior Care unit 10/25/10 with a diagnosis of Dementia with behavioral disturbances, possible dementia with psychosis.

A review of the medical record identified the patient had scraped the left side of his back on Geri-chair trying to get up 11/8/10 as documented by the nurse in her assessment.

The nurse documentation on 11/9/10 did not mention a scrape to his back but did document,"Skin tear left arm, Tegaderm to skin tear change every 72 hours."

There was no order in the medical record for the use of Tegaderm.

The nurse documentation on 11/10/10 did not mention a scrape to the back but did list Tegaderm under the wound care section.

The nurse documentation on 11/11/10 did not mention a scrape to the back, skin tear or use of Tegaderm but did document under wound care,"Yeast on groin area."

The nurse documentation on 11/12/10 documented,"No skin breakdown noted."

In a response to written questions provided to administrative staff 11/17/10, Employee Identifier # 1, the Chief Operating Officer of Sunrise confirmed 11/18/10 at 8:30 AM, there was no order for the Tegaderm. EI # 1, stated that the scrape was not treated as it was not a problem.

3. MR # 17 was admitted to the Senior Care unit 11/12/10 with a diagnosis of Dementia, likely Alzheimer's-type with behavioral disturbance.

There was an order written by the physician 11/13/10, " Clean wound to coccyx with normal saline, pat dry with 4x4, apply skin coat perimeter wound cover with Duoderm. Check dressing everyday and change dressing every 5 days and PRN (as needed) x 14 days."

The nurses documentation for 11/14/10 documented, "Wound care Granulex."

There was no mention of Duoderm being used as ordered and no order in the medical record for Granulex.

The nurses documentation for 11/15/10 documented, "Wound care Granulex/ Duoderm."

The interventions on the impaired skin integrity form documented, "Physician to assess wound, order treatment as appropriate and assess effectiveness of treatment every day and or as needed. Consult wound care for assessment and treatment recommendations as indicated..." There was no mention of the use of Granulex or Duoderm.

In a response to written questions provided to administrative staff 11/17/10, EI # 1 confirmed there was no order for the use of Granulex and the interventions were as documented on 11/18/10 at 7:50 AM.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings include:

Refer to Life Safety Code violations.