HospitalInspections.org

Based on document review and interview the hospital failed to protect patients from neglect.

Findings:
Review of 5 incontinent-patient charts showed that persons known to be incontinent of urine and/or stool were to be checked for incontinence (clean and dry), and turned in bed, at two (2) hour intervals. The charts further showed that patients were visited by staff but the assessments for incontinence and/or turning were not addressed, in the charts, as being done on each of those visits. In 4 of 5 patient charts the timing of notes concerning incontinence checks and/or turning the patient were as much as 5 hours apart. Interviews with Nursing Program Specialist, Quality Accreditation Manager, and Informatics nurse concurred that the charts showed excessive time between incontinence checks and positioning/repositioning notes.

The Nursing policy named "Assessment/Reassessment" does not describe which specific details comprise assessments or reassessments. No mention is made of hands-on physical assessment or notations of such things as skin condition, including bed-sores, vital signs, continence/incontinence, respiration, circulation, or other specific items of possible concern. The Nursing Program Specialist and Quality Accreditation Manager verified that no such language is contained in the policy.

Skin assessments for 1 of 2 patients was limited to "Braden Scale" comments and ratings. No instance of visualization of the skin, including existing or new skin abnormalities, was documented at any point in the patient chart including assessments either initial assessment or at patient discharge.
On the 2nd patient, a skin visualization note was made at initial assessment. However, all other assessment notes, including at patient discharge, were limited to "Braden Scale" comments and ratings. The Nursing Program Specialist concurred with the fact that "Braden Scale" ratings were used as skin assessments.
(Note: Braden scale is to classify RISK of skin damage. It does not indicate current problems)

Based on interview and record review the hospital failed to ensure that a registered nurse was properly evaluating the care of each patient.

Finding:
Review of 5 incontinent-patient charts showed that persons known to be incontinent of urine and/or stool were to be checked for incontinence (clean and dry), and turned in bed, at two (2) hour intervals. The charts further showed that patients were visited by staff but the assessments for incontinence and/or turning were not addressed, in the charts, as being done on each of those visits. In 4 of 5 patient charts the timing of notes concerning incontinence checks and/or turning the patient were as much as 5 hours apart. Interviews with Nursing Program Specialist, Quality Accreditation Manager, and Informatics nurse concurred that the charts showed excessive time between incontinence checks and positioning/repositioning notes.