HospitalInspections.org

Based on medical record review and interview, the facility failed to provide ongoing assessment of the skin for one patient (#3) of 3 patients reviewed.

The findings included:

Medical record review revealed Patient #3 was transported by a medical flight to the Emergency Department (ED) on 6/6/16 arriving at 4:48 PM following an ATV (all-terrain vehicle) roll-over accident.

Medical record review of the Trauma History and Physical dated 6/16/16 revealed the patient had fractures of the ribs on the right and a nondisplaced 1st rib fracture on the left. Continue review revealed the patient had an abrasion on the bridge of the nose, a 1 centimeter (cm) puncture wound of the lower left leg, and a 2 cm skin tear to the right upper extremity. Further review revealed the puncture wound was not surgically closed.

Medical record review of the nursing Clinical Notes Report dated 6/6/16 at 7:09 PM revealed the patient's care was transferred from the ED to the Trauma Patient Care Unit (TPCU).

Medical record review of the Clinical Notes Report dated 6/6/16 and timed 7:13 PM revealed the patient assessment included "...multiple abrasions and bruises..."

Medical record review of the Clinical Note Reports from admission on 6/6/16 at 9:13 PM to discharge on 6/8/16 at 3:04 PM, revealed no documention of assessment or treatment of the abrasion on the bridge of the nose, the puncture wound of the lower left leg, and the skin tear to the right upper extremity.

Interview with the Unit Manager of the TPCU on 8/23/16 at 5:20 PM, in the Manager's office, confirmed there was no documentation of an assessment or treatment of the patient's abrasion, skin tear, or puncture wound. Further interview confirmed it was standard of practice to document assessment of identified wounds each shift.

Based on medical record review and interview, the facility failed to ensure continuation of home pain management therapy for one (#2) of eight patients reviewed for pain management.

The findings included:

Medical record review revealed Patient #2 presented to the facility on 8/4/15 with left shoulder pain and palpitations associated with Atrial Fibrillation with Rapid Ventricular Response. Further review revealed the patient had a history of Post-Polio syndrome with weakness of the left lower extremity. The patient was discharged home on 8/5/15.

Medical record review of the History and Physical (H & P) dated 8/4/15 revealed "...[patient] reports...takes narcotic pain medication for right osteoarthritic knee pains and for...left lower extremity post-polio syndrome associated pain." Further review of the assessment and plan revealed "Post-polio syndrome. Will plan on continuing home pain medications."

Medical record review of the Nursing Admission Medication Reconciliation Report dated 8/4/15 revealed a list of home medications for Patient #2, obtained by Registered Nurse (RN #4), did not include any pain medications.

Medical record review of the Physician's orders, Medication Administration Record, and list of home medications revealed no documentation of a home narcotic pain medication.

Interview with the admitting Physician (MD #1) on 8/22/16 at 8:00 AM, in the nursing administration office, confirmed the physician obtained information from the patient during the admission evaluation and the patient reported home medications included a narcotic medication for pain management. Continued interview revealed, "I did not have a complete list of home meds [medications] at the time I dictated the H & P." The physician stated, "It was clearly my intention to continue the narcotic pain medication; unfortunately this one fell through the cracks." Continued interview revealed the physician evaluated and admitted the patient and did not see the patient again prior discharge and the physician assuming care of the patient after admission did not monitor the plan to ensure the home medication regimen was continued.

Interview with the Risk Manager on 8/22/16 at 9:00 AM, in the nursing administration office, confirmed the facility failed to ensure the physician's plan to continue the patient's regimen of pain management was implemented.