HospitalInspections.org

Based on observation, record review and interview the facility failed to provide physician ordered assistive devices for 1 of 1 patients (#1) who had falls during hospitalization, resulting in increased risk of falls for all patients. Finding include:

Patient #1:
Observation:
On 10/29/14 at 1055 patient #1 was observed resting in bed with a rolling walker beside the bed.

Record Review:
On 10/29/14 at 1100 review of patient #1's clinical record revealed a physician's order, dated 10/26/14, for a wheelchair and lap-buddy. There was no order for a rolling walker. The wheelchair with lap-buddy was ordered after patient #1's second fall on 10/26/14.

Interview:
On 10/29/14 at 1115 Nurse C confirmed that patient #1 had no orders for a rolling walker and stated that it should not have been parked at the patient's bedside. Nurse C stated that patient #1's order for a wheelchair and lap-buddy was still in effect.

Based on observation, interview and record review the facility failed to provide organized nursing services in accordance with the nursing process of identifying and responding to patient needs through assessment, care planning and documentation, resulting in increased risk of unmet care needs for all patients. Findings include:
--The facility failed to provide assessment, monitoring and treatment for 1 current patient (#9) and 1 discharged patient (#8) with HIV (Human Immunodeficiency Virus). (A-0395)
--The facility failed to monitor the wounds of 1 current patient (#12). (A-0395)
--The facility failed to provide assistive equipment in accordance with physician's orders for 1 current patient (#1). (A-0395)
--The facility failed to clearly document the allergies of 1 current patient (#10). (A-0395)
--The facility failed to provide 3 current patients (#1, #6 and #9) with care plans documenting specific goals and interventions to address physical health problems. (A-0396)

Based on observation, interview and record review the facility failed to supervise and evaluate the nursing care of 4 current patients (#1, #9, #10 and #12) and one discharged patient (#8) resulting in increased risk of poor health outcomes for all patients. Findings include:

Patient #9:
Record Review:
On 10/29/14 and 10/30/14 from 0900-1700 patient #9's clinical record was reviewed revealing the following:
1. Patient #9 was admitted 10/25/14 at 1145. A "RN Admission Note" by Nurse M, dated 10/25/14 at 1145 stated that the patient is a "poor historian" and "very confused." The admission "Body Graph" shows multiple scabbed areas on the patient's forehead and bilaterally on the anterior lower legs. No orders for wound care were noted.
2. The "Admission Medication Reconciliation" list for patient #9, dated 10/25/14 at 1145 by Nurse M, lists only one medication for treatment of HIV, "Truvada 400 mg. PO QD (by mouth each day)."
3. A History & Physical by Dr. K, dictated 10/25/14 at 1147, lists diagnoses of: psychosis, superficial abrasions and Human Immunodeficiency Virus (HIV).
4. On 10/26/14 at 0930 Nurse M noted: "Pt (patient) scratches at face, several times so far today...Pt loose in thought and grandiose."
5. On 10/26/14 at 2100 nurse O noted: "Pt (patient) at approx. (approximately) 1830 had a BM (bowel movement) in the community rest room on the male hall in which pt. had smeared fecal matter all over the toilet and floor as well as his gowns and socks."
6. No nursing interventions were documented in response to the patient's smearing of feces and picking at scabs on 10/26/14.
7. No attempts to clarify the patient's HIV medications with the Emergency Contact person was found.

Interviews:
1. On 10/29/14 at 1550 Nurse M was unable to explain why Truvada 400 mg. was ordered on 10/25/14 since the medication does not exist in that dosage. Nurse M stated that Social Workers make contact with families and may get updated information on patient medications.
2. On 10/29/14 at approximately 1600 Social Worker S stated that she spoke with the patient's Emergency Contact person, a family member who lives with the patient. Staff S stated that she did not ask the patient's contact person for information on the patient's current HIV medications.
3. On 10/29/14 at approximately 1900 patient #9's Emergency Contact person, was interviewed by phone. The contact person listed four medications that patient #9 takes at home for treatment of HIV. The contact person stated that she had spoken with a facility Social Worker but that nobody from the facility had requested information on the patient's HIV medications.
4. On 10/29/14 at approximately 1530 patient #9 was interviewed while resting in bed. The patient was awake but did not respond to questions. This observation was confirmed by Nurse B.
5. On 10/30/14 at 1030 patient #9 was observed lying in bed with an uncovered slightly bloody forehead wound, approximately 2 cm (centimeters) in circumference. This observation was confirmed by Nurse B. Nurse B asked a staff nurse to dress the wound.
6. On 10/30/14 at 1035 only one toothbrush was observed in the patient #9's shared bathroom. This observation was confirmed by Nurse B.
7. On 10/30/14 at 1040 patient #9's roommate (patient #4) was interviewed. Patient #4 stated that he had received no instructions for storage of personal toiletries. This interview was confirmed by Nurse B.
8. On 10/29/14 at 1140 patient #9 was interviewed in the Stereo Room. Patient #9's speech was unintelligible. The patient had a Band-Aid suspended above the bloody forehead wound, from the top of the forehead to the tip of the nose. Nurse B ordered a staff nurse to immediately redress the wound, to fully cover it.

Patient #12:
Record Review:
On 10/29/14 from 1150-1200 patient #12's clinical record was reviewed. Patient #12 was admitted on 10/26/14 with bilateral self-inflicted anterior thigh wounds, documented on the "Body Graph" on 10/26/14. The History & Physical by Physician R, dated 10/27/14, stated: "The patient has 8 staples placed in the right thigh. I did not examine the laceration. I will have Nursing take a look at this in a day with dressing changes daily." There was only one nursing note documenting a wound observation and dressing change, dated 10/27/14. Only the condition of the stapled wound was documented at that time. No wound observations or dressing changes were documented from 10/27/14 at 1900-10/29/14 at 1150.

Observation:
On 10/29/14 at 1200 patient #12's thigh wounds were assessed. There was no dressing in place. The staples were intact with no redness or discharge along the staple line. Multiple scratches on both upper thighs appeared to be healing. One of the scratches, measuring approximately 6 cm long, appeared to be slightly reddened. These observations were confirmed by Nurse J.

Interviews:
1. On 10/29/14 at 1200 patient #12 stated that she did not recall any staff assessments of the thigh wounds being done.
2. On 10/29/14 from 1150-1200 Nurse J confirmed record review findings (above) and stated that he was not aware of a facility policy or procedure for documenting patient wound assessments. Staff J stated that patient #12's record did not contain a physician's order for dressing changes.

Patient #10:
Policy Review:
Review of Policy 3.06.00, Drug/Food Sensitivity & Interaction Alerting System, dated 7/2012, was conducted on 10/30/14 at approximately 1600. The policy stated,
"The nursing staff member will record any sensitivity on the allergy tape on the front of the patient chart, on the medication administration record, and on the patient's Kardex."

Record Review:
On 10/29/14 at 1140 review of patient #10's medical record revealed tape on the front of the chart listing three allergies, "PCN (Penicillin), Demerol and Sulfa." These three allergies were also listed for patient #10 on the "Report Board."

Interview:
1. On 10/29/14 at approximately 1145 Nurse D, the Medication Nurse on duty, was asked to name patient #10's allergies. Nurse D looked at the allergies listed in the MAR (Medication Administration Record) for patient #10 on 10/29/14. Nurse D responded, "Demerol." Nurse D confirmed that the MAR for 10/29/14 listed only one allergy (Demerol) for patient #10.
2. On 10/29/14 at approximately 1150 Nurse C stated that the allergies listed for patient #10 should match on the patient's chart, Report Board and MAR.

Patient #1:
Observation:
On 10/29/14 at 1055 patient #1 was observed resting in bed with a rolling walker beside the bed.

Record Review:
On 10/29/14 at 1100 review of patient #1's clinical record revealed a physician's order, dated 10/26/14, for a wheelchair and lap-buddy. There was no order for a rolling walker. The wheelchair with lap-buddy was ordered after patient #1's second fall on 10/26/14.

Interview:
On 10/29/14 at 1115 Nurse C confirmed that patient #1 had no orders for a rolling walker and stated that it should not have been parked at the patient's bedside. Nurse C stated that patient #1's order for a wheelchair and lap-buddy was still in effect.

Patient #8:
Record Review:
On 10/3014 from 1230-1600 patient #8's clinical record was reviewed revealing the following:
1. Patient #8 was admitted on 7/12/14 with a diagnosis of HIV (Human Immunodeficiency Virus). On 7/13/14 Dr. R ordered Emtricitabine-tenofovir (Truvada) 1 cap. PO daily and Raltegravir (Isentress) 400 mg. daily. An order for Emtriva 200 mg. 1 PO daily was added on 7/13/14. These orders remained in effect until 8/20/14, when Truvada was discontinued. An order to restart Truvada was entered on 8/26/14.
2. Review of MAR (Medication Administration Record) entries for July-August 2014 revealed the following:
-On 7/14/14 Emtricitabine-tenofovir, Raltegravir, and Emtriva 200 mg. were all marked "NA" and circled.
-On 7/15/14 Truvada and Isentress 400 mg. appeared on the MAR and Emtriva 200 mg. dropped off the MAR without being discontinued by a physician. The MAR stated "Pt (patient) to use own meds (medications)" for the Truvada and Isentress.
-From 7/16/14-7/17/14 and 7/19/14-7/31/14 "NA" was noted at each daily Truvada administration time.
-In August 2014, Truvada was marked "NA" in the MAR on the following dates: 8/1/14-8/11/14 and 8/14/14-8/18/14. Isentress 400 mg. was circled or marked "NA" from 8/14/14-8/17/14.
3. On 7/21/14 Physician Q noted patient #8's statement, "I need my HIV meds (medications)." No response to this request was documented.
4. A 8/17/14 physician's order states: "Please re-order HIV medications Tenofovir 1 tab (tablet) PO (by mouth) daily & Isentress 400 mg. PO BID (twice daily).

Interviews:
1. The above findings were confirmed by Nurse B during record review on 10/30/14 from 1230-1600.
2. On 10/30/14 at approximately 1400 Nurse B stated that "NA" in the MAR means not available and that circled initials indicate that a medication was not given. Nurse B stated that this patient's family was supposed to bring in the patient's HIV medications but there was a problem with finding a physician to prescribe the medications because the patient had not been seen for lab work or appointments recently. Nurse B confirmed that documentation of the facility's efforts to address this problem was not found during record review, with the exception of one physician's order, dated 8/17/14, requesting that the above medications be re-ordered. Nurse B stated that the facility does not have a procedure for addressing the needs of HIV patients who do not have a current prescriber for HIV medications.

Based on document review and interview, the facility failed to ensure that nursing staff maintained updated treatment plans for 3 of 4 current patients (#1, #9 and #6) resulting in increased risk of poor health outcomes for all patients. Findings include:

Policy Review:
Policy review was conducted on 10/30/14 at approximately 1610.
Policy #2.21.00, Individualized Plan of Service (IPOS)/Treatment Planning, dated 10/2013, states:
-"The initial treatment plan shall be compiled at the time of admission."
-"The IPOS is completed within 72 hours of admission and is based on the initial assessments of the physician, nurse, behavioral health clinician and other professionals"
-"The IPOS shall be reviewed and updated at weekly meeting of the interdisciplinary team."
-"The plan shall include...assessment of the patient's need for...healthcare"

Record Review & Interview:
-On 10/30/14 at approximately 1300 review of patient #9's Individual Plan of Service (IPOS) revealed that there were no specific goals or interventions pertaining to the patient's HIV diagnosis, aimed at minimizing the risk of infection for patient #9 and other patients. This finding was confirmed by staff B on 10/30/14 at approximately 1300.

-On 10/29/14 at approximately 1115 review of patient #1's IPOS revealed no specific goals or interventions pertaining to the patient's falls. There was no evidence of a weekly update to the IPOS. These findings were confirmed by staff C on 10/29/14 at approximately 1115.


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On 10/29/14 at approximately 1130 review of patient #6's Interdisciplinary Plan of Service (IPOS) revealed that the patient's original treatment objectives were initiated on 10/15/14 and 10/16/14 with a target date of 10/20/14, to meet and/or reevaluate the objectives. There was no evidence in the medical record that indicated it had been updated since admission when the original Plan was created.

On 10/29/14 at approximately 1145, the findings for patient #6 were confirmed by staff Z, it was stated, "We had a meeting, however I did not specifically document on it." This surveyor then asked, "Did any of the other team members document, such as the nurse or physician?" Staff Z stated, "Not that I can find."