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Based on medical record review, policy and procedure review and interview Staff Nurses (Registered Nurses / RN and Licensed Practical Nurse / LPN) failed to document the specific location, size and color of brusing, skin tears and swelling noted to Patient Identifier (PI) # 1's upper and lower extremities during the initial skin assessment on 8/4/14 at 19:44 and subsequent skin assessments. As a result of this failure, there was no baseline to determine improvement or decline in the condition of PI #1's skin, a patient receiving Coumadin (blood thinning medication) with a history of a fall, skin tears, fragile skin, and reported physical aggression. Subsequent skin assessments also failed to describe the color and size of bruising and/or the size of skin tears. This affected PI # 1, one of ten sampled patients.

Findings include:

Based on a review of PI # 1's Emergency Room (ER) medical record PI # 1 presented to the Hospital's ER on 8/4/14 at 13:28.

The Chief Complaint as documented by the ED Physician: "Brought in by son; acting strangely this past week. He feels (PI # 1) needs placement in NH (Nursing Home); behavioral check-out is needed 1st per son." No complaint of pain.

Review of Systems: "Bruising," documented, but does not describe location, size and/or color.

Physical Examination: Cooperative.

Psychiatric: Behavior Normal...Oriented x 4. Affect/Mood Normal? "Not per son." Judgement/Insight ok ?: Y (yes) Memory Intact? Y Delusions ?: Y.

X-Ray Left Knee: "The study is performed on 8/4/14 at 14:25 for pain after a fall."
Results: Soft tissue injury. Degenerative Joint Disease.

8/4/14 14:05:

PT (Prothrombin): (a blood test that measures the time it takes for the liquid portion (plasma) of your blood to clot, Medline Plus, A service of the U.S. National Library of Medicine and the National Institutes of Health.

Result: 17.3 H (High) Reference Range: 10.5-13.5 seconds

Final Diagnoses:
1. Recent change in behavior; irrational per son
2. Alzheimer's new onset versus progressive

Decision to Admit: 8/4/14 at 16:30


Psychiatric Evaluation: 8/6/14:

Chief Complaint: "My elbow hurts."

HPI (History of Present Illness): The patient was brought her by her son...had become increasingly confused and agitated and had been having auditory and visual hallucinations...has become physically aggressive towards him (son).

History of A Fib (Atrial fibrillation: an irregular and often rapid heart rate that commonly causes poor blood flow to the body. (Mayo Clinic Website)

Current Medications Include:

"Warfarin 1 gram po (by mouth) per day" (Coumadin /warfarin sodium is a blood thinning medication),


Nursing Assessment:
8/4/14 19:44: "...Skin tear to right hand that was old skin tear, steri strips applied...several "bruised" on arms and legs...

8/5/14 21:27: "...While doing assessment left elbow red, warm to touch, bandaid over a new broken area in the skin, brusing on left forearm..."

8/6/14 10:08 : "Both arms has bruising...skin tears to right hand."

8/7/14 23:14: "...Skin tear to right lower arm with dry dressing intact, fragile skin, pink, swollen to left upper arm."

8/8/14 14:43: "Pt (patient) noted to have swollen red arm left side with swelling that extends from wrist to above elbow..."

8/9/14 08:55: "Right arm from elbow to fingers bruised (healing) with 4 intact steri strips on right hand...Left arm bruising Healing..."

8/10/14 23:05: "...left arm red, warm to touch, area swollen/puffy...small open area near elbow."

8/11/14 04:46: "...Bruised area on back of right upper leg..."

8/11/14 09:00: Written progress nurses by RN: "...skin tear on L (left) leg..."

8/11/14 17:57: PI # 1 discharged to 3rd floor.


Policy and Procedure Reviews:

1. Initial Patient Assessment and Reassessment
Effective / Revised: 10/17/11

Policy: "Each patient admitted to (name of hospital) shall receive a complete head to toe assessment...so that a plan of care can be developed to best meet the needs of the patient. The assessment...will be ongoing throughout the patient's hospital stay, with the assessment individualized to meet the needs of the patient population....

The patient assessment will include content regarding:
...Skin integrity

2. Protocols for Infected Skin/Cellulitis (document not dated)

...II. Wound Assessment:

A. RN/LPN to mark erythematous (redness of skin) borders on admission in order to assess cellulitis progression or improvement.

B. Assessment to include size, depth, tissue involvement, and the presence, extent, and cause of infection (if know)...

During an interview on 8/21/14 at 09:15 the Assistant Director of Nursing, Employee Identifier (EI) # 1 was asked if PI # 1's arm should have been measured to monitor swelling. EI # 1 said, "Yes. I believe the cellulits protocol calls for measuring."

Based on medical record review, review of policy and procedure and interviews, the Licensed Practical Nurse (LPN) failed to administer Keflex (antibiotic medication to treat infection) 500 milligrams (mg.) po TID (three times per day) in accordance with the physician's order for the treatment of pain, redness and warmth of Patient Identifier (PI ) #1's left arm. The LPN also failed to document the reason for the delay in administration of the first dose of Keflex and the reason the second dose of Keflex was not administered four hours after the first dose was given. This failure affected PI # 1, one of ten sampled patients.

Findings include:

Psychiatric Evaluation: 8/6/14:

Chief Complaint: "My elbow hurts."

HPI (History of Present Illness): The patient was brought here by son...had become increasingly confused and agitated and had been having auditory and visual hallucinations...has become physically aggressive towards him (son).

A verbal Physican's Order for Keflex 500 mg. (milligrams) po (by mouth) TID (three times per day) was given by the attending psychiatrist on 8/5/14 at 23:06.

A review of the Nursing Note dated 8/5/14 at 23:32 revealed, "Dr. (psychiatrist's name) look at pt. (patient) left forearm, x-ray ordered, at. (antibiotic) ordered. Continue with warm, red, painful to touch."


A review of PI # 1's Medication Administration Record (MAR) revealed:

- Keflex was scheduled at 09:00, 13:00 and 21:00 beginning 8/6/14 :

- The first dose of Keflex 500 mg. (milligrams) po (by mouth) was given on 8/6/14 at 11:32 (12 hours and 26 minutes after the order written).

- The second dose was administered on 8/6/14 at 13:09. According to hospital policy the second dose was scheduled four hours after the first dose.


A review of the Hospital's Policy and Procedure: Standardized Hours for Drug Distribution dated 10/17/11 revealed:

"Medications shall be given 30 minutes before the stated time or 30 minutes after the stated time."

Interviews

During an interview on 8/21/14 at 11:45, the Registered Pharmacist (Employee Identifier/ EI # 2) was asked how medication ordered after the pharmacy is closed is obtained. The Pharmacist said the House Supervisor can access the pharmacy after hours and obtain medication. The pharmacist verified PI # 1's order for Keflex 500 mg. po TID written on 8/5/14. The pharmacist was asked if Keflex is maintained on the nursing unit and she stated she was not sure, but Keflex is available in the pharmacy. The pharmacist stated she would verify if Keflex is available on the nursing unit, but there was no further response from the pharmacist.


During an interview on 8/21/14 at 12:00, the Licensed Practical Nurse (LPN / EI # 3) verified Keflex was scheduled TID (three times per day) and verified that she administered Keflex to PI # 1 on 8/6/14 at 11:32 and 13:09. The LPN was asked the reason the first dose of Keflex, scheduled at 09:00, was not given until 11:32 on 6/6/14. The LPN said she was waiting on the Keflex to arrive on the unit from Pharmacy. The LPN was also asked why she administered the second dose of Keflex at 13:09. The LPN said, "I figured (PI # 1) needed her antibiotic and it wouldn't hurt (PI #1)."

Keflex was ordered on 8/5/14 because PI #1's left arm was red, warm and painful. The physician ordered Keflex for the treatment of these symptoms. However, the first dose of Keflex was not administered until 12 hours and 26 minutes after the medication was ordered. According to
hospital policy the second dose should have been administered four hours later, but it was given one hour and 37 minutes after the first dose was administered. No documentation was found in the medical record to support the reason Keflex was not given as ordered by the physician.