HospitalInspections.org

Based on observation, interview, record review and policy review, the facility failed to provide ongoing nursing assessments for two patients (#6, and #18) of two patients whose medical records were reviewed for nursing assessments related to acute medical conditions. This failed practice had the potential to lead to deterioration of medical conditions and could affect all patients in the facility with acute medical issues. The facility census was 94.

Findings included:

1. Record review of the facility's policy titled, "Assessment," revised 05/15/14, showed the nurse shall assess each patient as needed throughout the shift and that daily nursing assessments are conducted every shift using the "Psychiatric Technician (PT) /Security Aide (SA) Flow Sheet" to reflect each patient's physical and psychiatric condition.

Record review of the facility's policy titled, "Documentation," reviewed 11/13, showed the PT/SA flow sheet was used to record observation and care provided each shift; was the responsibility of the Registered Nurse (RN); Licensed Practical Nurse (LPN); and PT/SA, and that the nurse shall review the information documented on the flow sheet and incorporate into the progress notes.

2. Record review of Patient #6's medical record showed the following:
- Admission orders dated 10/06/10 for Milk of Magnesia (laxative medication to relieve constipation).
- Medication Administration Record dated 08/26/14, indicated that the patient did not receive medication to relieve constipation.
- PT/SA Flowsheet for 08/14, that indicated the patient did not have a bowel movement (poop/stool) from 08/06/14 until 08/11/14.
- Progress notes did not indicate daily nursing assessments of the patient's gastrointestinal (GI, pertaining to the patient's abdomen and intestines) system.

3. Observation on 08/27/14 at 9:40 AM showed Patient #18 in the hall outside of her room in a wheel chair. She wore a sock on the right foot that covered a bulky bandage. The wheelchair was not equipped with attachments to elevate her legs.

Record review of Patient #18's Report of Operation dated 12/29/11 showed the patient received a surgical procedure for the removal of the right great toe and connecting foot bone which extended upward into her foot due to a long-standing non-healing bone infection. A chronic ulcer (poor healing wound) on the right foot received surgical removal of non-healing skin tissue.

Record review of Patient #18's Monthly Physician Progress Note, dated 08/07/14, showed:
- She had ongoing pain and was not able to walk due to right foot surgical procedures which included removal of her right great and third toes and removal of poor healing skin tissue in a skin ulcer. (The date of the third toe removal was not found in the medical record.)
- She received ongoing wound care to her right foot at the facility every day and also at a clinic outside the facility monthly.
- Cellulitis (skin infection from bacteria which had spread through the skin to deeper tissues) was present in her right lower leg.
- Her right leg was swollen and was oozing (leaking fluid).
- Her legs were to be elevated four to six times every day for 60 minutes.
- A urinary tract infection (UTI) was present and treated with two antibiotics (medication for the treatment of a bacterial infection).
- She had several episodes of incontinence.

During an interview on 08/27/14 at 9:40 AM, Patient #18 stated that her right foot, her back and neck hurt a lot. She stated she soiled her pants at times because the medicine for her UTI caused her to have frequent loose stools and she leaked urine. She did not remember if facility staff assisted or reminded her to use the toilet. She reported she received wound care to her right foot and she did not elevate her legs often.

During an interview on 08/28/14 at 1:20 PM, Staff Q, Registered Nurse (RN), who was assigned care of Patient #18 stated that she was not familiar with the status of the patient's wound. Staff Q stated that nurses did not document the wound care, wound assessments or any specific care related to the patients wound or skin care needs. She stated that the nurses performed patient assessments on all patients one time a year and documented in patients progress notes two times a month unless something significant changed in their status. She stated that the patient care techs would tell the nurses if something changed. Staff Q confirmed no nursing assessment had been conducted on Patient #18's urinary tract infection, wound and skin care, compliance with leg elevation, pain and or comfort needs and measures to promote improved toileting.

4. During an interview on 08/28/14 at 2:30 PM, Staff N, Nurse Manager, confirmed that patient assessments were conducted yearly and nursing progress notes were documented on each patient twice a month. She stated that more frequent documentation by nursing staff was needed to reflect ongoing assessment and oversight of the patient's physical/medical nursing needs. Staff N stated that Patient #18 and all other patients in the facility were at a risk for deterioration in medical and mental health conditions and needed daily nursing assessments, nursing care and re-evaluation to ensure progress in their care.

During an interview on 08/26/14 at 1:45 PM Staff I, RN, stated that nurses did an annual assessment of the patient. Nurses also did twice a month nursing progress note and entered additional progress notes as needed but there are no additional nursing assessments done.

During an interview on 08/27/14 at 1:35 PM Staff L, RN, stated that nurses did an annual assessment of the patient. Nurses also did twice a month nursing progress note and entered additional progress notes as needed but there are no additional nursing assessments done. Staff L stated that she was not aware of any change in patient condition that would have resulted in an additional patient assessment.

5. During an interview on 08/28/14 at 9:20 AM, Staff B, Director of Quality Management, stated that there was room for improvement in the staffs' documentation and that patient information was not consistently documented in the medical record. Staff B stated, "Anybody should be able to go into the medical record and see what's going on with the patient and if it isn't documented, it didn't happen."

6. During an interview on 08/28/14 at 10:15 AM, Staff C, Chief Nursing Executive, stated, "You're not going to find regularly documented assessments in the (patient's medical) record", because there was no expectation for a daily nursing assessment. Staff C added that without frequent assessments, psychiatric and/or medical concerns may be overlooked.


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Based on observation, interview, record review and policy review, the facility failed to ensure that patients' nursing care plans were developed and kept current for two patients (#6, #18) of 11 patients whose medical records were reviewed for nursing care plan goals and interventions. This had the potential to affect all patients by failing to ensure that the patients' physical and psychological needs were met. The facility census was 94.

Findings included:

1. Record review of the facility's policy titled, "Treatment Planning and Documentation," revised 01/16/14, showed that the treatment planning process included the identification of problems and goals, and relevant interventions as determined by on-going assessments of patients' needs.

2. Record review of Patient #6's medical record showed the following:
- Admission orders dated 10/06/10 for Milk of Magnesia (laxative medication to relieve constipation).
- Psychiatric Technician/Security Aide Flowsheet for 08/14, that indicated the patient did not have a bowel movement (poop/stool) from 08/06/14 until 08/11/14; and
- Treatment plan dated 05/01/14, did not indicate problems, goals or interventions related to the patient's gastrointestinal system (pertaining to the stomach and intestines).

During an interview on 08/26/14 at 3:50 PM, Staff G, Lead Registered Nurse (RN), stated that the patient had very large bowel movements (stool/poop).

During an interview on 08/27/14 at 3:10 PM, Staff F, RN, along with Staff G, stated that Patient #6 had previously been placed on laxatives for constipation, but they didn't work, and that the patient's care plan did not include nursing interventions or goals for the patient's constipation because there was nothing they could do for the patient's constipation.

3. Observation on 08/27/14 at 9:40 AM, showed Patient #18 in the hall outside of her room in a wheelchair, her right foot was covered in a bulky bandage. The wheelchair wasn't equipped with attachments to elevate her legs.

Record review of Patient #18's Monthly Physician Progress Note, dated 08/07/14, showed:
- She had ongoing pain and was not able to walk due to right foot surgical procedures which included removal of her right great and third toes and removal of poor healing skin tissue in a skin ulcer.
- She received ongoing wound care to her right foot at the facility two times a day and also at a clinic outside the facility monthly.
- Cellulitis (skin infection from bacteria that had spread through the skin to deeper tissues) was present in her right lower leg.
- Her right leg was swollen and was leaking fluid from the skin surfaces.
- Her legs were to be elevated four to six times every day for 60 minutes.
- A urinary tract infection (UTI) was present and treated with two antibiotics (medication for the treatment of a bacterial infection).
- She had episodes of incontinence (had a loss or lack of bowel and/or bladder control).

During an interview on 08/27/14 at 9:40 AM, Patient #18 stated that:
- Her right foot, legs, back and neck hurt often.
- The nurses told her they would give her more pain medicine but they never did.
- The wounds on her feet hurt so bad at times, she "could hardly stand it."
- The medicine for the UTI caused loose stools and she could not get to the bathroom quick enough so she soiled herself and leaked urine.
- She did not remember if facility staff assisted or reminded her to use the toilet.
- She received wound care to her right foot and she did not elevate her legs often.

Record review of Patient #18's care plans dated 07/28/14, showed no identified problems, goals or nursing care for Patient #18's wound and skin care, pain/comfort, bowel and bladder problems (UTI), or cellulitis.

During an interview on 08/27/14 at approximately 2:15 PM, Staff Q, RN assigned to Patient #18, stated that there were no care plans developed for Patient #18's wounds, skin care, pain/comfort, bowel/bladder problems (UTI) or cellulitis.




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