HospitalInspections.org

Based on record review and interview the facility failed to include post-operative restrictions on the nursing plan of care in 8 of 8 spinal surgery patients (Pt. #1, #3, #5, #6, #7, #8, #9, #10).

Findings:

The facility's "Lumbar Fusion/Laminectomy Post Surgical Spine" defines the following post-surgical spinal precautions for patients: "1. Do not bend forward at the waist... 2. Do not lift more than 10 pounds. 3. Do not twist trunk while performing any activity. 4. Do not cross knees or ankles while sitting, standing or lying. 5. Always log roll out of bed."

Per Pt. #1's MR, reviewed 2/25/2015 at 1:30 p.m., Pt. #1 was admitted to the facility on 12/9/2014 for laminectomy surgery (decompression spinal surgery). The PT POC note documents "Lumbar precautions: Yes." The nursing POC does not include documentation of lumbar/back precautions or restrictions.

Per Pt. #3's MR, reviewed 2/25/2015 at 12:10 p.m., Pt. #3 was admitted to the facility on 1/6/2015 for laminectomy surgery. The PT POC note documents "Lumbar precautions: Yes." The nursing POC does not include documentation of lumbar/back precautions or restrictions.

Per Pt. #5's MR, reviewed 2/25/2015 at 1:20 p.m., Pt. #5 was admitted to the facility on 12/16/2014 for cervical fusion surgery. The PT POC note documents "Lumbar precautions: Yes." The nursing POC does not include documentation of lumbar/back precautions or restrictions.

Per Pt. #6's MR, reviewed 2/25/2015 at 1:30 p.m., Pt. #6 was admitted to the facility on 1/6/2015 for lumbar fusion surgery. The PT POC note documents "Lumbar precautions: Yes." The nursing POC does not include documentation of lumbar/back precautions or restrictions.

Per Pt. #7's MR, reviewed 2/25/2015 at 12:55 p.m., Pt. #7 was admitted to the facility on 2/24/2015 for laminectomy surgery. The PT POC note documents "Lumbar precautions: Yes." The nursing POC does not include documentation of lumbar/back precautions or restrictions.

Per Pt. #8's MR, reviewed 2/25/2015 at 1:05 p.m., Pt. #8 was admitted to the facility on 2/24/2015 for laminectomy surgery. The PT POC note documents "Lumbar precautions: Yes." The nursing POC does not include documentation of lumbar/back precautions or restrictions.

Per Pt. #9's MR, reviewed 2/25/2015 at 1:50 p.m., Pt. #9 was admitted to the facility on 1/27/2015 for laminectomy and fusion surgery. The PT POC note documents "Lumbar precautions: Yes." The nursing POC does not include documentation of lumbar/back precautions or restrictions.

Per Pt. #10's MR, reviewed 2/25/2015 at 2:00 p.m., Pt. #10 was admitted to the facility on 1/27/2015 for laminectomy surgery. The PT POC note documents "Lumbar precautions: Yes." The nursing POC does not include documentation of lumbar/back precautions or restrictions.

During an interview on 2/25/2015 at 12:30 p.m., PT Mgr B stated the PT staff documents care precautions based on the type of surgery, but the PT notes are not integrated with nursing notes or the nursing POC.

Based on record review and interview the facility failed to ensure that nursing staff ' s orientation documentation accurately reflected their competency to care for patients on the medical-surgical unit for 3 of 3 personnel records reviewed (CNA J, CNA K, CNA L). This has the potential to affect all 34 patients receiving care at this facility.


Findings:

The facility's "CNA Orientation Core Competency/Skills Checklist" states the following directions for completion: "3.)...Complete ALL Essential Education; these are required...5.) Your preceptor and/or RN must date and initial next to each behavior when you demonstrate competence of Required Behaviors...6.)...Once your preceptor/RN have determined you are competent and ready to come off orientation you need to sign and date the last page of the document."

CNA J's orientation documentation, reviewed on 2/25/2015 at 3:05 p.m., revealed CNA J started working at the facility on 10/30/2013. CNA J was not validated as competent on the orientation checklist in the following areas: Safe Patient Handling; Restraints; Communication and Ethical Conduct; Providing Daily Hygiene Cares; Acute Care of the Elderly Concepts; Maintaining Skin Integrity; Care of the Diabetic Patient and Care of the Surgical Patient. CNA J did not sign the orientation checklist indicating competence. CNA J's "Final Evaluation of Orientation" dated 2/2014 states CNA J "is competent to independently care for patients..." without a complete core competency checklist.

CNA K's orientation documentation, reviewed on 2/25/2015 at 3:05 p.m., revealed CNA K started working at the facility on 4/7/2014. CNA J was not validated as fully competent on the orientation checklist in the following areas: Communication and Ethical Conduct; Maintaining Skin Integrity; Care of the Diabetic Patient and Care of the Surgical Patient. CNA K did not sign the orientation checklist indicating competence. CNA K was deemed "competent to independently care for patients" without a complete or signed orientation core competency checklist.

CNA L's orientation documentation, reviewed on 2/25/2015 at 3:05 p.m., revealed CNA L was not validated as fully competent on the orientation checklist in the following areas: Safety; Acute Care of the Elderly Concepts; Maintaining Skin Integrity; Care of the Diabetic Patient; Elimination and Care of the Surgical Patient. The checklist is not signed by CNA L and the facility deemed CNA L "competent to indepently care for patients" as of 11/2014.

CNS I stated "if something is incomplete we review as needed after completion of orientation."