HospitalInspections.org

Based on interview and record review the facility failed to provide written notice to all patients that there is no doctor of medicine or osteopathy present in the hospital 24 hours per day, seven days per week resulting in all patients previous and 86 current, not receiving this information. Finding include:

Record Review:
On 10/30/13 at 1500 review of patient admission documents revealed that patients are not provided with a written statement revealing that a physician is not on-site at all times.

Interview:
On 10/30/13 at 1530 the above findings were confirmed with Nurse A.

Based on document review and interview, the facility maintained 1 of 3 patients (#21) in mechanical restraints without documentation of aggressive behaviors to justify restraint use resulting in increased risk of all patients being unnecessarily restrained. Findings include:

Policy:
Restraints- Behavioral Services, dated 3/2013 states: "Restraints may only be imposed to ensure the immediate physical safety of the patient...and must be discontinued at the earliest possible time."

Record Review:
On 10/29/13 from 1400-1500 review of patient #21's clinical record revealed a "Restraint & Seclusion Flowsheet" dated 10/6/13 stating that patient #21 had orders for "walking restrains while awake." An order for "two point ambulatory" restraints was obtained from physician Q at 1634 on 10/6/13. At 1725 patient #21's restraints were "released for meals." From 1740-2010 there was no documentation of aggressive behavior but the patient was not released from restraints. A new order for "2-point ambulatory restraints was obtained at 2040. From 2040-2245 there was no documentation of behaviors to justify continued restraint use.

Interview:
Patient #21's physical restraint documentation (above) was confirmed by staff A from 1400-1500 on 10/30/13.

This CONDITION is not met as evidenced by:

Based on observation, interview and record review the facility failed to provide organized nursing services that follow the nursing process of identify and respond to patient needs through assessment, care planning and documentation resulting in increased risk of unmet care needs for all patients. Findings include:
--The facility failed to provide monitoring and treatment for 1 current patient (#14) and 1 discharged patient (#9) who with diagnoses of Diabetes Mellitus and wounds, with documentation of blood glucose monitoring and wound status . (A-0395)
--The facility failed to provide 4 of 4 current patients (#12, #13, #14 and #16) and 3 of 3 discharged patients (#9, #10, and #20) with care plans documenting objectives and interventions for medical problems and care needs. (A-0396)

Based on document review and interview 1 of 1 current patients (#14) and 1 of 2 discharged patients (#9 ), with diagnoses of Diabetes Mellitus and wounds, the facility failed to assess and monitor nursing care resulting in increased risk of harm for all patients with diabetes or wounds. Findings include:

Policy Review:
Nursing Process: Documentation, dated 3/20/13 states:
2. "Included in comprehensive charting are the patient's general appearance, activity, general behavior..."
8. "The nursing staff will utilize the nursing process, which is a systematic problem-solving approach consisting of assessment, diagnosis, planning, implementation and evaluation."
9. "Progress notes should be done on each shift, on each patient for each day of hospitalization. These should include the following:
a. "Progress or lack of progress in relation to nursing care and Master Treatment Plan goals."
b. "Observations regarding changes in a patient's condition."

Record Review, patient #14:
1. On 10/29/13 from 1145-1200 review of patient #14's medical record revealed an admission date of 9/23/13. The "Visual Body Check," done at admission, revealed no documentation of alterations in skin integrity for either foot.
2. On 10/29/13 from 1145-1200 review of patient #14's Medication Administration Record revealed an order for Lantus 25 mg. subcutaneous every evening, starting on 9/24/13.
3. On 10/29/13 from 1145-1200 review of patient #14's record revealed an assessment of patient #14's right foot, by physician R, dated 10/7/13, stating: "Minor cut under the right 4 th toe, no signs of infection, discussed wound care to the area with washing the area with soap and water, keeping the area dry and clean after washing and well ventilated...very mild scale of the skin at the bottom of the foot."
4. On 10/30/13 at 10 am record review revealed a telephone order for "Naftin apply small amount BID (twice daily) to feet." No description of the condition or area of the foot being treated were documented.
5. On 10/29/13 from 1145-1200 review of patient #14's record revealed no follow-up assessments of patient #14's right foot skin impairments.

Observation:
On 10/30/13 from 1020 and 1110 observations of patient #14's feet revealed that the ball of the right foot was red with pealing skin. A superficial line of cracked, dried skin, approximately .5 cm across, was observed under the 4 th toe. Two brown spots measuring .25-.5 cm., were observed on the bottom, center of patient #14's right foot.

Interview:
1. On 10/30/13 from 1020-1110 Nurse L confirmed the (above) observations of patient #14's feet.
2. On 10/30/13 at approximately 1020 patient #14 stated that the brown spots at the center, bottom of the right foot had been present for 4-6 weeks and were a sign of "uncontrolled diabetes."
3. On 10/30/13 at 1000 Nurse M stated that there was "no standard way to document wounds."
4. On 10/30/13 at approximately 1040 Nurse L confirmed that patient #14's clinical record did not contain nursing assessments of patient #14's feet despite a cut being documented on 10/7/13 and Naftin cream treatment being ordered on 10/25/13. Nurse L stated that "observations of patient #14's feet should have been documented by nurses in progress notes and included in the patient's Master Treatment Plan."


30988

Based on observation, interview and record review the facility failed to provide organized nursing services that follow the nursing process to provide monitoring and treatment for one discharged patient (#9) with diagnoses of Diabetes Mellitus and wounds, with documentation of blood glucose monitoring and wound status. Findings include:

10/29/13 at approximately 1400 during record review of patient #9 the following was found:
1. Physician admission note 6/22/13 at 1030 Axis 111 diagnosis-" Hypertension, diabetes, gunshot wound, cellulitis."
2. Nursing assessment of systems completed 6/22/13 (no time documented), skin assessment-"redness around gunshot wound (GSW) area on left leg, endocrine assessment-"non insulin dependant diabetes mellitis, Blood glucose level- 152 at 805."
3. Visual body search documents "wound on left leg".
4. Physician order 6/22/13 at 1515 for" Dry wound dressing daily ".
5. Physician order 7/1/13 at 0941 for "silvadene cream to thigh wound apply once daily with dressing change."
6. Nursing note 6/22/13 at 1650 documenting dressing change and wound assessment.
7. Clinical note 6/27/13 at 0232 by mental health assistant (MHA) stating resident "reported that he needed his dressing changed."
8. Nursing note 6/29/13 at 0510 documents "resident at nurses desk requesting to have his blood sugar checked (due to self-reported symptoms)."
9. Master treatment Plan begun on 6/22/13 recorded only 1. problem- "alteration in thought." No documentation was found for physical problems to be addressed.
There was no further documenting of dressing changes or assessments of the wound.
There was no further documentation of blood glucose checks.

Interview of staff A on 10/29/13 at 1600 regarding the documentation for patient #9 stated, "the daily dressing changes should be documented, and the blood glucose should have been documented when the resident reported he needed it checked".
Interview of staff P on 10/30/13 at 1330 regarding documentation for patient #9 stated, "non insulin dependant diabetics have their level checked on admission and then only if the patient is symptomatic or if they request it checked, the daily dressing changes would be done as ordered."

Review of Policies-
1. Nursing Process Documentation #8.05.01 last revised 3/2013, states under general information, "9. Progress notes should be done on each shift, on each patient, for each day of hospitalization....should include the following...b. Observations regarding changes in patients condition... "
2. Nursing Note Progress Form #8.05.02 last revised 3/2013 states "Documentation should be reflective of each patients progress....also aids in evaluation of nursing care and reflects quality." and under "Procedure ........4)..If there is anything outside of a normal range, document who the information was reported to..."

Based on document review and interview,-The facility failed to provide 4 of 4 current patients (#12, #13, #14 and #16) and 3 of 3 discharged patients (#9, #10, and #20) with care plans documenting objectives and interventions for medical problems and care needs. Resulting in increased risk of unmet care needs and less than optimal patient outcomes. Findings include:

On 10/29/13 at approximately 1400 during record review of patient #9's medical record, the "master treatment plan" begun on 6/22/13 lists in Axis 111 diagnosis, "cellulitis, gunshot wound, Diabetes mellitus, and Hypertension." The problem list has only one problem listed, #1 "Alteration in thought." There was no problem or plan addressing the physical needs of the patient (i.e. dressing changes, wound care, blood glucose checks).

On 10/30/13 at approximately 1000 during record review of patient #20, the "master treatment plan" begun 7/16/13 has Axis 111 "diagnosis of Hypertension, Diabetes, hypothyroid, Ichthyosis...." The problem list had only one problem listed, "#1 suicidology." There is no problem or plan addressing the physical needs of the patient (insulin dependance, blood glucose checks, Nutrition).

Interview of staff A on 10/30/13 at approximately 1400 stated "There is nothing in the master treatment plan addressing the physical needs of the patients".


27065


Policy Review:
Treatment Plan, dated 3/20/13, states: "Each patient will have a comprehensive, individualized master treatment plan that will identify patient problems, strengths, and severity of illness based upon an interdisciplinary patient assessment."
Nursing Process Documentation, dated 3/2013, states:
9. "Progress notes should be done on each shift, on each patient for each day of hospitalization. These should include the following:
a. Progress or lack of progress in relation to nursing care and Master Treatment Plan goals."

Record Review, patient #14:
1. On 10/29/13 from 1145-1200 review of patient #14's medical record revealed an admission date of 9/23/13. The "Visual Body Check," done at admission, revealed no documentation of alterations in skin integrity to either foot.
2. On 10/29/13 from 1145-1200 review of patient #14's "Master Treatment Plan" revealed a diagnosis of DM (Diabetes Mellitus) Type II.
3. On 10/29/13 from 1145-1200 review of patient #14's Medication Administration Record revealed an order for "Lantus 25 mg. subcutaneous every evening, starting on 9/24/13." The Master Treatment Plan diagnosis was not changed from Type II to Type I (insulin-dependent) Diabetes Mellitus after insulin was started.
4. On 10/29/13 from 1145-1200 review of patient #14's record revealed an assessment of patient #14's right foot, by physician R, dated 10/7/13, stating: "Minor cut under the right 4 th toe, no signs of infection, discussed wound care to the area with washing the area with soap and water, keeping the area dry and clean after washing and well ventilated...very mild scale of the skin at the bottom of the foot."
5. On 10/30/13 at 1000 review of patient #14's record revealed a telephone order for "Naftin apply small amount BID (twice daily) to feet." No description of the condition or area of the foot being treated were documented.
6. On 10/29/13 from 1145-1200 review of patient #14's record revealed that the patient's "Master Treatment Plan" was not updated to change the diagnosis of Type II Diabetes Mellitus to Type I after insulin orders were added. The patient's impaired skin integrity and treatments to the feet were not included in the Master Treatment Plan.

Observation:
On 10/30/13 at 1020 and 1110 observations of patient #14's feet revealed that the ball of the right foot was red with pealing skin. A superficial line of cracked, dried skin, approximately .5 cm across, was observed under the 4 th toe. Two brown spots measuring .25-.5 cm., were observed on the bottom, center of patient #14's right foot.

Interview:
1. On 10/30/13 from 1020-1110 Nurse L confirmed the (above) observations of patient #14's feet.
2. On 10/30/13 at approximately 1020 am patient #14 stated that the brown spots at the center, bottom of the right foot had been present for 4-6 weeks and were a sign of "uncontrolled diabetes."
3. On 10/30/13 at approximately 1040 Nurse L confirmed that patient #14's clinical record did not contain nursing assessments of patient #14's feet despite a cut being documented on 10/7/13 and Naftin cream treatment being ordered on 10/25/13. Nurse L stated that observations of patient #14's feet "should have been documented by nurses in progress notes and included in the patient's Master Treatment Plan."
5. On 10/29/13 at 1105 Nurse A verified that there was no documentation of objectives or interventions in patient #14's Master Treatment Plan for Diabetes Mellitis or impaired skin integrity for the foot cut and scale documented by physician R on 10/7/13.

Record Review, patient #12
1. On 10/29/13 at 1040 patient #12's clinical record revealed a "History and Physical" dated 10/23/13 stating, "Patient is non-verbal due to autistic disorder."
2. On 10/29/13 from 1040-1100 a review of patient #12's record revealed 10/25/13 and 10/27/13 progress notes stating that the "patient needs assistance with toileting and 'ADLs' (Activities of Daily Living.)"
3. On 10/29/13 from 1040-1100 review of patient #12's Treatment Plan revealed no objectives or interventions for communication, toileting, bathing or other ADLs.

Interview:
1. The findings (above) were confirmed by staff A during record review on 10/29/13 from 1040-1100.
2. On 10/30/13 at approximately 1125 staff N stated the patient needs assistance with toileting and bathing.

Record Review, patient #16's:
1. On 10/29/13 from 1105-1130 review of patient #16's clinical record revealed a "History and Physical" dated 10/25/13, stating that the patient was "alert but not noting any spheres of orientation and noting a diagnosis of 'Autistic Spectrum Disorder.'"
2. On 10/29/13 from 1105-1130 review of patient #16's Nursing Assessment states: "(patient) needs direction and getting water temperature correct, needs guidance in cleaning peri area."
3. On 10/29/13 from 1105-1130 review of patient #16's Treatment Plan revealed no objectives or interventions for toileting or bathing.

Interview:
1. The findings above were confirmed by staff A during record review on 10/29/13 from 1105-1130.
2. On 10/30/13 at approximately 1125 staff N stated the patient needs assistance with toileting and bathing.