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Based on record review, document review and staff interview it was determined the Governing Body failed to ensure appropriate medical services were provided to meet patient needs for 1 (#6) of 10 sampled patients. This practice does not ensure patients receive safe and quality medical care.

Findings include:

1. Patient #6 was admitted in transfer from an acute care facility on 1/10/13 at 10:22 p.m.

Admitting physician orders dated 1/10/13 at 8:55 p.m. ordered a chest x-ray to be performed the following morning.

The History and Physical dated 1/11/13 at 5:12 a.m. and signed by the attending physician at 7:19 p.m. revealed the patient was transferred from the acute care facility and was on a ventilator. The assessment of the patient's respiratory system was documented as respirations were non-labored. The History and Physical included documentation indicating an order for a routine consultation with a pulmonologist for respiratory failure was entered into the electronic order processing system on 1/11/13 at 7:18 p.m.

The chest x-ray results dated 1/11/13 indicated the study was performed at 9:20 a.m. and signed by the radiologist on 1/11/13 at 9:24 a.m. The radiologist findings were complete opacification of the left hemithorax with possible volume loss. This may be due to a large effusion and/or atelectasis. The findings indicated a significant impairment of the patient's respiratory system.

Progress notes dated 1/12/13 at 2:21 p.m. and signed by the attending physician contained no indication the attending physician had reviewed or was aware of the results of the chest x-ray. The physical exam for respiratory documented the lungs were clear to auscultation. The plan was to continue ventilator support, follow stool studies and to continue tube feeding.

A pulmonology consultation dated 1/12/13 was dictated by the pulmonary Advanced Registered Nurse Practitioner (ARNP) at 11:12 a.m. The physical examination included documentation that the patient had inspiratory and expiratory wheezes with diminished air exchange on the left and dullness to percussion on the left. The impression included left lung collapse with volume loss and chronic kidney disease Stage IV.

An interview was conducted on 2/20/13 at approximately 11:00 a.m. with the Registered Nurse (RN) Infomatics Liaison. He confirmed the findings that the patient was on a ventilator at the time of admission on 1/10/13. He confirmed the findings that the chest x-ray on 1/11/13 at 9:20 a.m. indicated there was problem with the patient's left lung. He confirmed the finding that the attending physician ordered a routine pulmonary consultation on 1/11/13 at 7:19 p.m., approximately 10 hours following the chest x-ray that indicated the patient's left lung was not functioning properly. He confirmed the finding the attending physician's progress notes dated 1/12/13 at 2:21 p.m., approximately 28 hours following the chest x-ray, did not indicate the attending physician had reviewed or was aware of the chest x-ray findings and the physician had documented the patient's lungs were clear to auscultation.

2. Patient #6's progress notes dated 1/13/13 at 8:56 a.m. and signed by the pulmonary ARNP noted the patient had a large cuff leak. (The inflated balloon or cuff surrounding the tracheostomy tube that seals and secures the tracheostomy tube within the patient's trachea. Loss of air in the cuff can cause instability in the tracheostomy and can cause ineffective delivery of mechanical ventilation.) She noted the patient's arterial blood gases were stable. The plan documented she discussed the cuff leak with the pulmonologist. The pulmonologist indicated he would replace the tracheostomy tube following a bronchoscopy that was planned for the following morning (1/14/13).

Respiratory Therapy (RT) notes dated 1/13/13 at 9:00 p.m. indicated the tracheostomy tube had become unstable and was not secure in the patient's trachea. The respiratory therapist had removed the tracheostomy tube and replaced it with an endotracheal tube in accordance with the facility's emergency airway maintenance protocol. The therapist notified the pulmonologist of the event.

The progress notes date 1/14/13 at 7:35 a.m. indicated the pulmonologist planned to request a consultation with a surgeon to replace the tracheostomy.

The Operative Report dated 1/16/13 and signed by the surgeon indicated he removed the endotracheal tube and used a guide to insert the new tracheostomy tube into the patient's trachea. The procedure was successful and the patient tolerated the procedure well.

An interview was conducted on 2/21/13 at approximately 11:00 a.m. with the respiratory therapist who was in attendance during the tracheostomy replacement procedure on 1/16/13. He indicated when the surgeon attempted to slide the new tracheostomy over the guide, it broke in two pieces in his hands.

An interview was conducted on 2/22/13 at approximately 12:30 p.m. with the surgeon who had performed the tracheostomy procedure on 1/16/13. He described the guide as a light blue, flexible, plastic rod approximately two feet long and somewhat smaller than a pencil in diameter. The end of the guide is curved at an angle for the final 1 1/2-2 inches. The surgeon explained the technique for replacing tracheostomies is to insert the curved end of the guide into the opening in the patient's neck, slide the old tracheostomy tube out over the guide and slide the new tracheostomy tube over the guide into place. He stated when he feels the new tube reach the curved portion of the guide, he knows the new tube is in the same position in the patient's trachea as the old one was and is in good position. The surgeon indicated on 1/16/13 he had just introduced the curved end of the guide into the old tracheostomy when it cracked right in the center. He placed the broken guide on the bedside table. He made a second attempt with another guide and stated it broke before he could even introduce it. The surgeon had to manually insert the new tube.

In response to questions, the surgeon indicated he did not examine the first guide, which had been introduced into the patient's trachea, to see if the broken pieces approximated the entire guide following the procedure. He stated he ordered a chest x-ray and requested the radiologist to examine the x-ray for foreign bodies. He stated he did not know if the guide was radio-opaque (specially treated so it would be seen on x-ray). He stated the chest x-ray confirmed the tracheostomy tube was in good position and was negative for foreign bodies. He indicated he reported the malfunction of the guides to the person in charge of Material Management the next morning.

Facility documentation noted the equipment failure was reported on 1/17/13 at 10:13 a.m. to the Pulmonary Department Manager. The documentation described the guide devices were brittle when manipulated. The report indicated the issue was discovered before any impact to patients.

The Operative Report dictated on 2/2/13 at 2:35 p.m. and signed by the pulmonologist indicated the patient underwent a bronchoscopy due to a worsening chest x-ray, worsening oxygen levels and infiltrates. The report indicated there was a foreign object seen in the distal trachea into the right mainstem bronchus (the far end of the trachea where the main airway leads to the right lung). Photographs accompanying the report showed a foreign object within the patient's trachea. The operative report documented the foreign body was removed.

A review of the medical record failed to reveal documentation of any further description of the foreign body by the physician performing the procedure. There was no documentation of the size, shape, color or indication of a possible source. There was no documentation the object had been sent to a pathologist for examination.

An interview was conducted with the respiratory therapist who was in attendance at the bronchoscopy performed on 2/2/13. He was also in attendance at the replacement of the tracheostomy tube on 1/16/13. He confirmed he witnessed the removal of the foreign body from the patient's trachea on 2/2/13. When asked if the foreign body was anything he had seen before or recognized, he stated he identified it as a piece of a guide device used in changing tracheostomy tubes. He stated it was a piece of light blue plastic rod, removed in two pieces, each approximately 10 millimeters in length.

An interview was conducted with the Risk Manager and the Quality Manager on 2/21/13 at approximately 3:00 p.m. In response to questions, they stated neither of them were aware of any of the above documented events.

They confirmed the finding that the attending physician assessed the patient's lungs as being clear to auscultation at the time a chest x-ray documented the patient's left lung was collapsed. They confirmed the finding that the documentation dated 1/17/13 erroneously documented patients were not affected by the malfunction of the guides used to perform the tracheostomy replacement procedure on 1/16/13.

The Risk Manager acknowledged that expected physician behavior would be to examine the broken pieces of an instrument that had been introduced into a patient's trachea to attempt to determine if all of the broken pieces was removed in its entirety or if pieces could not be accounted for.

The Risk Manager and the Quality Manager confirmed the finding there was no documentation the foreign body removed by the pulmonologist on 2/2/13 had been retained for examination. They confirmed there had been no report of the removal of the foreign body to the facility's Risk Manager, Quality Director, or the Medical Staff. In response to questions, the Quality Manager indicated she depended on the submission of information to identify issues with quality of care by physicians.

The medical record review and interviews determined the medical staff did not provide care to meet the needs of respiratory patients.

Based on record review, document review and staff interview it was determined the facility failed to develop and maintain an effective Quality Management program for monitoring, tracking and trending adverse events related to the quality of medical services provided to patients. This practice does not protect patients from similar events or issues.

Findings include:

1. Patient #6 was admitted in transfer from an acute care facility on 1/10/13.

Chest x-ray results dated 1/11/13 indicated the study was performed at 9:20 a.m. and signed by the radiologist on 1/11/13 at 9:24 a.m. The radiologist findings were complete opacification of the left hemithorax with possible volume loss. This may be due to a large effusion and/or atelectasis. The findings indicated a significant impairment of the patient's respiratory system.

Progress notes dated 1/12/13 at 2:21 p.m. and signed by the attending physician contained no indication the attending physician had reviewed or was aware of the results of the chest x-ray. The physical exam for respiratory documented the lungs were clear to auscultation.

A pulmonary consultation dated 1/12/13 was dictated by the pulmonary Advanced Registered Nurse Practitioner (ARNP) at 11:12 a.m. The physical examination included revealed the lungs had inspiratory and expiratory wheezes with diminished air exchange on the left and dullness to percussion on the left. The impression included left lung collapse with volume loss.

An interview was conducted on 2/20/13 at approximately 11:00 a.m. with the RN Infomatics Liaison. He confirmed the findings that the chest x-ray on 1/11/13 at 9:20 a.m. indicated a problem with the patient's left lung. He confirmed the finding that the attending physician ordered a routine pulmonary consultation on 1/11/13 at 7:19 p.m., approximately 10 hours following the chest x-ray that indicated the patient's left lung was not functioning properly. He confirmed the finding that the attending physician progress notes dated 1/12/13 at 2:21 p.m., approximately 28 hours following the chest x-ray did not indicate the attending physician had reviewed or was aware of the chest x-ray findings and the physician had documented the patient's lungs were clear to auscultation.

An interview was conducted with the Risk Manager and the Quality Manager on 1/21/13 at approximately 9:30 a.m. They confirmed the finding that the attending physician's assessment of the patient's respiratory system did not correlate with the findings reported on the chest x-ray. Both stated they had received no information from the other physicians who cared for the patient and reviewed the records in the course of providing care or from any of the facility staff involved in the care regarding any concerns with the attending physician's assessment.

2. Progress notes dated 1/13/13 at 8:56 a.m. and signed by the pulmonary ARNP noted the patient had a large cuff leak. She noted the patient's arterial blood gases were stable. She indicated she discussed her findings with the pulmonologist who planned to request a surgical consult to replace the tracheostomy tube.

Respiratory Therapy notes dated 1/13/13 at 9:00 p.m. indicated the tracheostomy tube had become unstable and was not secure in the patient's trachea. The respiratory therapist had removed the tracheostomy tube and replaced it with an endotracheal tube in accordance with the facility's emergency airway maintenance protocol. The therapist had notified the pulmonologist of the event.

The Operative Report dated 1/16/13 and signed by the surgeon indicated he removed the endotracheal tube and used a guide to insert the new tracheostomy tube into the patient's trachea.

An interview was conducted on 2/22/13 at approximately 12:30 p.m. with the surgeon who had performed the tracheostomy procedure on 1/16/13. He described the guide as a light blue, flexible, plastic rod approximately two feet long and smaller than a pencil in diameter. The end of the guide is curved at an angle for the final 1 1/2-2 inches. The surgeon explained the technique for replacing tracheostomies is to insert the curved end of the guide into the opening in the patient's neck, slide the old tracheostomy tube out over the guide, and slide the new tracheostomy tube over the guide and into place. He stated when he feels the new tube reaches the curved portion of the guide, he knows the new tube is in the same position as the old one was and is in good position.

The surgeon indicated on 1/16/13 he had just introduced the curved end of the guide into the old tracheostomy when it cracked right in the center. He placed the broken guide on the bedside table. He made a second attempt with another guide and stated it broke before he could even introduce it. He indicated he abandoned further attempts to use a guide and was successful in manually inserting the new tracheostomy tube into place without a guide. He stated he ordered a chest x-ray and requested the radiologist to examine the x-ray for foreign bodies. He stated he did not know if the guide was radio-opaque. He stated the chest x-ray confirmed the tracheostomy tube was in good position and was negative for foreign bodies. He indicated he reported the malfunction of the guides to the person in charge of Material Management the next morning.

Review of documentation revealed the equipment/medical device event occurred on 1/16/13 at 8:00 a.m. and was reported by the Material Manager on 1/17/13 at 10:13 a.m. to the Pulmonary Department Manager. The report described the guide devices were brittle when manipulated. The report documented the issue was discovered before any impact to patients.

An interview was conducted on 2/21/13 at approximately 9:40 a.m. with the respiratory therapist who was in attendance during the tracheostomy replacement procedure on 1/16/13.
He indicated he observed the surgeon insert the guide into the patient's trachea, and when the surgeon attempted to slide the new tracheostomy over the guide, the guide broke in two pieces in his hands. In response to questions, the respiratory therapist indicated following the procedure he didn't think about submitting a report.

An Operative Report dictated on 2/2/13 at 2:35 p.m. and signed by the pulmonologist indicated the patient underwent a bronchoscopy due to worsening chest x-rays, worsening oxygen levels and infiltrates. The report indicated there was a foreign object seen in the distal trachea into the right mainstem bronchus (the far end of the trachea where the main airway leads to the right lung). Photographs accompanying the report show a foreign object within the patient's trachea. The operative report documented the foreign body was removed.

An interview was conducted on 2/21/13 at approximately 9:40 a.m. with the respiratory therapist who was in attendance at the bronchoscopy performed on 2/2/13. He was also in attendance at the replacement of the tracheostomy on 1/16/13. He confirmed he witnessed the removal of the foreign body from the patient's trachea on 2/2/13. When asked if the foreign body was anything he had seen before or recognized, he stated he identified it as a piece of a guide device used in changing tracheostomy tubes. He stated it was a piece of light blue plastic rod, removed in two pieces, each approximately 10 millimeters in length. In response to questions, he indicated he was focused on the care of the patient and did not think about writing or submitting a report.

A telephone interview was conducted on 2/21/13 at approximately 10:35 a.m. with the RN who was assigned to the care of patient. She confirmed she was in attendance during the bronchoscopy on 2/2/13. She stated she observed the pulmonologist remove a foreign body from the patient's trachea. She described it as blue in color and probably 2 to 3 inches long. It was nothing she recognized or had seen before. In response to questions, she said her understanding of the facility policy regarding reporting was that whenever something happens a report should be filled out. She indicated she did not complete and submit a report because she thought the physician said he would complete a report.

A telephone interview was conducted on 2/21/13 at approximately 10:40 a.m. with the RN Wound Care Nurse. She confirmed she was in attendance during the bronchoscopy performed on 2/2/13. She stated she observed the physician remove a foreign body from the patient's trachea. She described it as light blue plastic. She was unsure of the size but thought maybe it was a couple of inches long. She indicated it looked like part of a "trach changer" (another term for the guide device used to change tracheostomies). In response to questions, she said she never thought about completing a report.

An interview was conducted on 2/21/13 at approximately 11:20 a.m. with Respiratory Therapist #2. In response to questions, she indicated a report should be submitted anytime something happens that results in harm to a patient.

An interview was conducted with the Risk Manager and the Quality Manager on 2/21/13 at approximately 3:00 p.m. In response to questions, they stated neither of them were aware of any of the above events concerning the care of the patient and no reports had been received related to those events. They confirmed the finding that the documentation dated 1/17/13 erroneously documented patients were not affected by the malfunction of the guides used to perform the tracheostomy replacement procedure on 1/16/13.

The Risk Manager and the Quality Manager confirmed the finding there was no documentation the foreign body removed by the pulmonologist on 2/2/13 had been retained for examination. They confirmed there had been no report of the removal of the foreign body to the facility's Risk Manager, Quality Director, or the Medical Staff.

They confirmed the finding the staff had failed to appropriately report the above events or concerns in compliance with facility policy. As a result, no investigation was performed or opportunity to improve patient care and safety were identified.

Based on medical record review, staff interview and review of policy and procedures it was determined the registered nurse failed to supervise and evaluate care related to assessing the needs of the patient for 2 (#2, #7) of 10 patients sampled, failed to ensure the patient was repositioned every two hours for 4 (#2, #3, #7, #8) of 10 patients sampled, failed to obtain a physician order for dressing changes for 2 (#5, #7) of 10 patients sampled and failed to obtain a physician order for medication in a timely manner for 1 (#6, #7) of 10 patients sampled. This practice does not ensure the provision of quality health care in a safe environment.

Findings include:

1. Patient #7 was admitted on 1/11/2013 at 9:30 p.m. Review of the record revealed no documentation an RN (Registered Nurse) completed an admission assessment nor assessed the patient during the shift on 1/11/2013 from 7:00 p.m. to 7:00 a.m. Review of the record revealed the first RN assessment was completed on 1/12/2013 at 7:00 a.m. Interview with the nurse manager on 2/20/2013 at 1:00 p.m. confirmed the above findings.

2. Patient #2 was assessed on 2/7/2013 at 7:00 a.m. by the RN. The patient's neurological and respiratory function were assessed. Review of the nursing documentation revealed no evidence the RN assessed the patient's cardiovascular system, breath sounds, gastrointestinal, genitourinary, musculoskeletal, integumentary, or Braden score. Review of the record revealed the patient was ventilated, unresponsive, and needed complete assistance. Documentation revealed the patient was receiving a tube feeding for nutrition, had an indwelling urinary catheter and was unable to move all extremities. Interview with the nurse manager on 2/21/2013 at 1:40 p.m. confirmed the above findings.

Review of the facility policy, "Assessment/Reassessment, Organization-Wide Plan for Patient", last revised 6/2012, states B Nursing Services (1) at the time of admission, patients will have their needs assessed by an RN; (e) unit specific timeframe's for reassessment for LTAC (Long Term Acute Care) patient is every shift and more frequently as needed.

3. Patient #2 was admitted on 2/4/2013 and required maximum assistance for all ADLs (Activities of Daily Living) including turning and repositioning every 2 hours per pressure ulcer prevention protocol. The patient was identified to be at high risk for skin breakdown. Review of the nursing documentation revealed from 2/6/2013 at 7:00 p.m. until 2/7/2013 at 7:00 p.m. there was no evidence of turning and repositioning every 2 hours. Interview with the nurse manager on 2/21/2013 at 1:40 p.m. confirmed the above findings.

4. Patient #3 was admitted on 2/6/2013 and required maximum assistance for turning and repositioning every 2 hours. Review of the following dates and times revealed no evidence the patient was turned and repositioned:
2/7/2013 from 9:00 p.m. to 2/8/2013 at 7:00 a.m.;
2/8/2013 from 7:00 p.m. to 2/9/2013 at 4:00 a.m.;
2/9/2013 from 6:00 a.m. to 9:00 p.m.
An interview with the nurse manager on 2/20/2013 at 2:15 p.m. confirmed the above findings.

5. Patient #7 was admitted on 1/11/2013 and required assistance for ADLs, including turning, repositioning and range of motion. On 1/11/2013 physician orders stated to turn back to side every 2 hours. Review of the medical record revealed on 1/12/2013 from 7:00 a.m. until 7:00 p.m. there was no documentation the patient was turned and repositioned. On 1/14/2013 from 3:00 p.m. until 9:00 p.m. documentation revealed the patient was lying on her right side with no evidence of turning and repositioning every 2 hours. On 1/16/2013 from 6:00 a.m. until 4:00 p.m. documentation revealed the patient was lying on her left side with no evidence of turning and repositioning every 2 hours. On 1/14/2013 nursing documentation revealed the patient had a pressure ulcer to the sacrum.

6. Patient #8 was admitted on 1/18/2013 and required maximum assistance for turning and repositioning every 2 hours. Nursing documentation revealed on admission the patient's skin was "not intact". There was no documentation that described the part of skin that was not intact and no documentation of treatment to the not intact skin. Review of the following dates and times revealed no evidence the patient was turned and repositioned:
1/19/2013 from 7:00 a.m. to 7:00 p.m., 1/20/2013 from 12:00 a.m. to 7:00 a.m., 1/20/2013 from 7:00 p.m. to 8:00 a.m. on 1/21/2013.
Interview with the nurse manager on 2/21/2013 at 10:00 a.m. confirmed the above findings.

7. Patient #5 was admitted to the facility on 2/11/2013. Review of the record revealed the patient had multiple pressure ulcers upon admission to the facility. The pressure ulcers were located on the sacrum and bilateral heels. Nursing documentation revealed the left heel and sacrum were being treated according to facility protocol and the right heel was receiving santyl/gent with a 4x4 and kerlix daily dressing change.

Interview with the nurse manager on 2/22/2013 at 10:25 a.m. confirmed the right heel dressing change required a physician order. Review of the record revealed no evidence of a physician order and no evidence of the daily dressing changes. The facility protocol for the sacrum was Xenaderm Allevyn BID (twice a day). Review of the record revealed no evidence of Xenaderm Allevyn to the sacrum BID. The facility protocol for the left heel was Allevyn with 3x3 dressing daily. Review of the record revealed no evidence of daily dressing changes to the left heel.

Interview with the nurse manager on 2/22/2013 at 10:25 am confirmed the lack of documentation for daily and BID dressing changes.

8. Patient #7 was admitted on 1/11/2013. Review of the record revealed the patient was admitted status post a debridement of a hematoma in the left groin. Review of the record revealed a wound vac was applied to the patient's wound with no evidence of a skin assessment prior to application, no evidence of a physician order for the wound vac and no evidence of the date, time, or staff member that applied the wound vac. A physician order dated 1/11/2013 stated to photograph all wounds on admission. Review of the record revealed the patient's wounds were photographed on 1/14/2013, three days after admission.

On 1/23/2013 a physician order was written to discontinue the wound vac and to complete dressing changes to the left groin with saline and apply silvasorb gel into the wound and cover with gauze and medipore tape every shift. Review of the record revealed the wound vac was discontinued on 1/23/2013 and the dressing changed per physician orders was completed. The left groin dressing was changed on 1/28/2013 at 1:00 a.m. and on 1/29/2013 at 10:00 a.m. Review of the record revealed lack of documentation the dressing was changed every shift as ordered by the physician.
Interview with the nurse manager on 2/20/2013 at 3:00 p.m. confirmed the findings.

9. Patient #7's physician admitting orders dated 1/11/2013 ordered Zyprexa 5 milligrams (mg) daily by mouth. Review of the MAR (Medication Administration Record) revealed the patient received Zyprexa 5 mg on 1/12/2013 at 10:22 am.

Review of nursing documentation dated 1/12/2013 at 6:00 p.m. indicated "patient's family brought in medication reconciliation with Zyprexa 2.5 mg and the patient is currently receiving 5 mg". Review of the record revealed no documentation the physician was notified at the time of the notification of the incorrect strength of the medication. The patient received two more doses on 1/13/2013 at 9:45 a.m. and 1/14/2013 at 10:19 a.m. of Zyprexa 5 mg.

Review of the physician's orders revealed on 1/14/2013 at 3:09 p.m. an order to change Zyprexa 5 mg daily to Zyprexa 2.5 mg daily, two days after nursing was informed of the correct dose and failed to notify the physician..

Interview with the nurse manager on 2/20/2013 at 1:00 p.m. confirmed the above findings.

10. Patient #6 was admitted to the facility on 1/10/12. Physician orders dated 1/10/13 at 11:00 p.m. indicated the patient's medications included Lispro (Humalog) insulin to be administered on a sliding scale, 2-10 units subcutaneously every six hours.

A review of the fingerstick glucose levels indicated the patient's blood sugar levels were steadily increasing despite the administration of the sliding scale insulin being administered as ordered. On 1/11/13 at 4:00 a.m. the serum glucose level was 135, at 5:11 a.m. it was 188, at 11:36 a.m. it was 226; at 4:53 p.m. it was 203 and at 10:37 p.m. it was 219. On 1/12/13 at 10:38 p.m. the glucose level was 240. On 1/13/13 at 12:42 p.m. the glucose level was 332.

A review of the medical record failed to reveal documentation of any communication between the nursing staff and the physician regarding the steadily increasing blood glucose levels until 1/14/13 at 5:37 p.m. when the patient's glucose level was reported as 417.

An interview was conducted with the RN Infomatics Liason, who confirmed the finding that the steadily increasing blood sugar levels indicated the patient's diabetes was not being adequately controlled with the sliding scale insulin.

Based on review of the medical record, staff interview and review of policy and procedures it was determined the nursing staff failed to develop and keep current a plan of care for a diabetic patient and communicate with the physician to develop a plan of care on a timely basis for two (#6, #7) of ten patients sampled. This practice does not ensure the patient's goals are met that may lead to a prolonged hospital stay.

Findings include:

1. Patient #7 was admitted to the facility on 1/11/2013. Nursing identified the patient required maximum assistance for ADLs (Activities of Daily Living) and wound care. Review of the record revealed the patient's plan of care was not initiated until 1/14/2013, three days after the patient was admitted. Review of the plan of care revealed discharge planning was not initiated on the plan of care until 1/30/2013, the day of the patient's discharge from the facility.

Review of the facility's policy, "Interdisciplinary Plan of Care", approved 10/2011, states (4) in order to ensure that the plan continues to be individualized and meeting the needs of the patient, the plan of care shall be reviewed by the clinician at regular daily intervals (not less than once per shift).

Review of the plan of care revealed lack of documentation that nursing reviewed the plan of care once per shift, lacked documentation if the patient was progressing toward the patient specific goals, and if problems, goals, and/or interventions were added, modified or discontinued based on the continued reassessment.

Interview with the nurse manager on 2/20/2013 at 3:00 p.m. confirmed the findings.


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2. Patient #6 was admitted to the facility on 1/10/12. Physician orders dated 1/10/13 at 11:00 p.m. indicated the patient's medications included Lispro (Humalog) insulin to be administered on a sliding scale, 2-10 units subcutaneously every six hours.

A review of the fingerstick glucose levels indicated the patient's blood sugar levels were steadily increasing despite the administration of the sliding scale insulin being administered as ordered. On 1/11/13 at 4:00 a.m. the serum glucose level was 135, at 5:11 a.m. it was 188, at 11:36 a.m. it was 226; at 4:53 p.m. it was 203 and at 10:37 p.m. it was 219. On 1/12/13 at 10:38 p.m. the glucose level was 240. On 1/13/13 at 12:42 p.m. the glucose level was 332.

A review of the medical record failed to reveal documentation of any communication between the nursing staff and the physician regarding the steadily increasing blood glucose levels until 1/14/13 at 5:37 p.m. when the patient's glucose level was reported as 417.

An interview was conducted with the RN Infomatics Liason, who confirmed the finding that the steadily increasing blood sugar levels indicated the patient's diabetes was not being adequately controlled with the sliding scale insulin.