HospitalInspections.org

Based on observation, record review and interview, the facility failed to ensure staff followed policies related to documentation of residual gastric fluid related to tube feedings for 2 of 2 patients (#2 & 10), failed to care plan 1 of 2 patients for aspiration risk related to feeding tubes (#2), and failed to ensure staff documented identified skin breakdown areas (non-pressure) including dressing changes on those areas for 1 of 3 patients (#5).

Findings:

1. Review of the medical record for patient #2 showed an admission on 7/03/13, discharge on 7/19/13 and a readmission on 7/31/13 for management of ventilator and weaning and treatment of pulmonary embolism and deep vein thrombosis. The patient was currently in the critical care unit at the hospital. Review of the care plan did not show a care plan for the nasogastric tube or the percutaneous endoscopic gastrostomy (PEG) tube related to gastric residual fluids (monitored for aspiration risk). Patient #2 had a nasogastric tube in place for feeding purposes from 7/31/13 to 8/22/13 when the PEG tube was placed.

Review of the documentation for 8/24/13 showed residual documented only 3 times; on 8/25/13 residual documented only 3 time; on 8/26/13 residual documented only 1 times; on 8/27/13 residual documented only 2 times; and on 8/28/13 residual was documented only 4 times.

2. Review of the medical record for patient #10 showed an admission on 8/23/13 for respiratory failure. The patient is currently residing in the critical care unit. The nasogastric tube was placed on 8/24/13 at 9:14 a.m. The X-ray was done at 12:28 p.m. to determine placement. The feeding was started at 8/24/13 at 6 p.m. per physician order.

Review of the care plan showed gastric residuals for patient #10 to be done every 4 hours. Review of the documentation for 8/25/13 showed residual documented only 4 times; on 8/26/13 residual documented only 1 time; on 8/27/13 residual documented only 2 times; and on 8/28/13 residual documented only 4 times.

During an interview on 8/29/13 at 9:45 a.m. the clinical nurse manager and the chief nursing officer both confirmed the documentation related to the feeding tube residual was inconsistent and patients in the critical care unit are considered critically ill patients.
Review of the policy "Enteral Nutrition", dated as last revised on 4/2013 read, "Check residuals every 4 hours in critically ill patients and every 6-8 hours in non-critically ill patients."

During an interview on 8/29/13 at 11:20 a.m., the dietitian said residual documentation is related to patient's risk for aspiration. She said if it is greater than 250 milliliters, this would be reported to the physician.

3. Review of the medical record for patient #5 showed an admission on 6/13/13 for respiratory failure, and gastrointestinal bleeding.

During an observation on 8/29/13 at 9:05 a.m., registered nurse #A turned the patient and showed areas on the patient's back with multiple dressings. She removed the one on his back to show an area of a skin tear on the left upper shoulder area. She pointed out the patient has multiple areas similar to this one on his arms, legs, and back area.

Observation of the patient's buttocks and coccyx showed no skin breakdown in that area. Record review of the patient's skin assessments showed only one skin tear documented on each of patient #5's forearms since 6/13/13. There is no documentation of the progression of the skin tear activity except on the patient right and left forearm areas. The chief nursing officer confirmed this is the only skin breakdown activity documented for patient #5.

Review of the policy "Prevention of Skin Breakdown", dated as released 2/2013, read, "Document all risk and skin assessments....Document all preventative measures....and.... Document collaboration with beside and ancillary staff."