HospitalInspections.org

Based on findings from document review, medical record (MR) review and interview, in 3 of 6 MRs reviewed for patients at risk of pressure ulcer development (Patients # 1,2 and 3), nursing staff did not consistently document turning and positioning, patient position and heel elevation.

Findings include:

-- The hospital's policy and procedure (P&P) titled "Skin Care Policy and Procedure," last revised 8/2016, described the following: Nursing staff assess a patients risk for pressure ulcer development using the Braden Scale score (Braden Scale) which requires scoring of patients risk factors. For patients at risk for pressure ulcer development (i.e., Braden score <18) nursing staff implement skin care guidelines that correspond to the Braden subscale scores. The frequency of turning and positioning of patient in bed is based on the following subscores. For subscores of 1, 2, or 3 in the Braden subscale areas of sensory perception, activity and mobility, or scores of 1 or 2 for friction and shear, nursing staff should reposition the patient every 2 hours (q2h) or more frequently if there is evidence of pressure on their skin. Heels should be elevated with pillows, heel protectors or floats. Repositioning should be documented in the MR including position patient was placed in.

Examples of lack of documentation include:

-- Per review of Patient #1's MR, on 10/31/16 at 07:10, nursing documented a Braden score of 12 (high risk) with an activity sub score of 1 (bedfast), mobility subscore of 2 (very limited) and friction and shear subscore of 2 (potential problem). At 11:00, nursing staff documented that Patient #1 was repositioned on right side. There is no further nursing documentation indicating that the patient was turned and repositioned until 19:28 (7.5 hours later) and there is no documentation the patient's heels were elevated.

-- Per review of Patient #2's MR, on 10/30/16 at 19:37 nursing documented a Braden score of 11 (high risk) with an activity sub score of 1, mobility subscore of 2 and friction and shear subscore of 1 (problem). At 18:03, nursing staff documented that Patient #2 was repositioned supine (on back). There is no further nursing documentation indicating that the patient was turned and repositioned until 10/31/16 at 06:58 (13 hours later) and there is no documentation the patient's heels were elevated.

-- The same lack of documentation of pressure ulcer prevention was noted in Patient #3's MR.

-- During interview of Staff A on 11/1/16 at 12:02, the above findings were acknowledged.

Based on findings from document review, interview and medical record (MR) review, 7 of 9 MRs (Patient #'s 1,3,4,5,6,7 and 8) lacked documentation of patient education as directed by the facility's policy and procedure (P&P).

Findings include:

-- Review of the facility's P&P titled "Patient Plan of Care," last revised 5/2014, indicated education is documented in narrative notes and on the patient education log.

-- During interview of Staff A on 11/2/16 at 10:40, he/she acknowledged that education topics could include, for example, medication teaching and blood transfusion reactions.

-- Review of Patient #3's MR revealed, she was admitted on 10/28/16 with a diagnosis of acute renal failure and hyperkalemia. On 11/1/16 (4 days later), the education log and narrative notes lacked documentation of patient education.

-- Review of Patient #4's MR revealed she was admitted to the facility on 10/19/16 with a gastrointestinal disorder. On 11/1/16 (13 days later), the education log and narrative notes lacked documentation of patient education.

-- The same lack of documentation of patient education on the education log and in narrative notes was noted for Patient #'s 1,5,6,7 and 8.

-- During interview of Staff A on 11/2/16 at 10:40, the above findings were acknowledged.

Based on findings from medical record (MR) review, document review and interview,
1) in 4 of 4 MRs, Patient #s 9,10,11 and 12 physician orders for continuous infusion of intravenous (IV) sedative medications and anesthetic medications were not complete,
2) the hospital's policies and procedures (P&P) related to high alert medications did not address all monitoring requirements associated with administration of these medications,
3) 4 of 4 MRs, Patient #s 9, 10, 11,12 lacked consistent nursing documentation of sedation levels, per sedation scale, for patients receiving IV sedative/anesthetic medications,
4) 4 of 4 MRs, Patient #s 9, 10, 11, 12 lacked consistent nursing documentation of medication dosages administered to patients during continuous IV infusion of sedative/anesthetic medications and 5) in 3 of 3 MRs (Patient #s 2,7 and 13) reviewed of patients who received a blood transfusion, physician orders lacked the duration of infusion. These lapses could lead to increased risk for adverse patient outcomes.

Findings regarding 1) above include:

-- Review of Patient #9's MR revealed on 2/1/16 at 8:39, a physician (Staff B) ordered infusion of dexmedetomidine (Precedex), a sedative medication, after bolus with 115 micrograms (mcg) with orders to titrate drip by 0.1 mcg/kilogram (kg)/hour (hr) every 20 minutes. Additionally, on 2/1/16 at 14:20 Staff B ordered propofol 1000 milligrams (mg)/100 ml infusion, an anesthetic medication, with order to call provider if dose reaches 50 mcg/kg/minute (min). These orders lacked parameters or goals that nursing should use for titration of the medication.

-- Review of Patient #10's MR revealed on 10/31/16 at 9:57, a physician, (Staff C) ordered propofol infusion to be started at 5 mcg/kg/min and to notify the provider if the rate reached 50 mcg/kg/min. The order lacked parameters or goals that nursing should use for titration of the medication.

The same lack of documentation of physician order parameters was noted in Patient #11's and #12's MR.

Findings regarding 2) above include:

-- Review of P&P related to high risk medication monitoring revealed lack of evidence of a process for patient risk assessment associated with administration of high risk medications, monitoring of the patient, including what should be monitored, frequency and duration of patient monitoring and/or monitoring methods that should be used.

-- Specifically related to the medication propofol, the hospital P&P titled "Sedation for Ventilated Adult," dated 12/2011, indicated that the physician should order a Modified Ramsey Score (MRS) (sedation scale) goal range when ordering sedation for the ventilated adult patient. However, per interview of Staff D on 11/1/16 at 12:00 pm, nursing staff are no longer instructed to use MRS and should presently use the Richmond Agitation Sedation Scale (RASS), another more specific scale to score patient's sedation level.

Findings regarding 3) above include:

-- Review of Patient #9's MR revealed that he was admitted on 1/31/16 with acute pancreatitis. During his hospitalization Patient #9 was on sedative/anesthetic medications (1/31/16 -2/7/16). Nursing staff documented sedation levels (per RASS) of +1 to +3 (restless to very agitated) every 2 hours from 1/31/16 to 2/2/16. However after this time (21:40) there are only 2 RASS scores documented by nursing through 2/7/16. Per interview of Staff E on 11/1/16 at 9:45 am the RASS should be documented at least every shift.

-- Review of Patient #10's MR revealed she was admitted on 10/31/16 with respiratory failure and placed on mechanical ventilation. On 10/31/16 at 9:57, Staff C (Physician ) ordered propofol (sedative) infusion to be started at 5 mcg/kg/min and to notify the provider if the rate reached 50 mcg/kg/min. During the duration of this medication infusion, there was no documentation by nursing staff indicating the patient's sedation level by a sedation scale.

The same lack of documentation of sedation levels (by a sedation scale) during infusion of sedatives/anesthetics was found in MRs for Patient #11 (review period 10/31/16-11/2/16) and Patient #12 (review period 10/29/16 to 11/2/16.)

Findings regarding 4) above include:

-- Review of Patient #9's MR revealed he was on sedative/anesthetic medications from 1/31/16 - 2/7/16. For example, from 2/1/16 at 16:00 to 2/7/16 at 11:03 Patient #9 was on a propofol infusion. Nursing staff documented hourly fluid intake for the propofol infusion ranging from 0 to 20 ml. However, there is no consistent documentation by nursing staff indicating the dosage of the medication administered.

-- Review of Patient #10's MR revealed she was mechanically ventilated and on a propofol infusion to be started at 5 mcg/kg/min and to notify the provider if the rate reached 50 mcg/kg/min. Other than nursing staff documentation on I&O sheet indicating hourly fluid intake of propofol infusion from 04:00 to 1:00 on 11/1/16 , there was no documentation indicating the specific dose of propofol administered to the patient.

The same lack of documentation of IV medication infusion dosages was found in MR for Patients #11 and #12.

-- Per interview with the Director of Regulatory Affairs (Staff G) on 11/3/16, he/she acknowledged the above findings.

Findings regarding 5) above include:

-- Review of Patient #13's MR, dated 10/29/16 at 22:48, revealed a physician order to transfuse red blood cells unit 1. No duration for the transfusion was specified.

-- The same lack of documentation regarding the duration of infusion was found in MRs for Patient #7 and Patient #2.

-- During interview with Staff A (Nurse Clinician) on 11/1/16 at 1:15, he/she acknowledged the above findings.