HospitalInspections.org

Based on record review and interview the nursing staff failed to assess and document wounds, document specific wound care that was provided and follow physician orders for wound care. This affected Patient Identifiers (PI) # 3 and PI # 9 , 2 of 2 sampled patients with wounds, and had the potential to affect all patients served.

Findings include:

1. PI # 3 was admitted to the hospital on 3/7/16 with diagnoses including Probable Exacerbation of Dementia Due to Medical Non compliance and Possibly Also Associated with Urinary Tract Infection and Heart Disease, Hypertension, Diabetes and Stroke by History.

Review of the Medical Intensive Care Unit (MICU) nursing assessment 3/7/16 revealed documentation under the Integumentary section, patient skin was described as warm/ dry, color within normal limits (WNL) and mucus membranes moist which was consistently documented during the stay in MICU 3/7/16, 3/8/16, 3/9/16 and 3/10/16. Patient was transferred to the Geriatric Behavioral Unit (Geri-Psych) on 3/10/16.

Further review of the MICU nurses notes on 3/7/16 at 1:45 PM revealed the Registered Nurse (RN) documented "no skin breakdown observed other than a small abrasion at the right side of the nose.

Review of the Geri Psych Nurse note 3/12/16 at 6:00 AM revealed the presence of a dark blister on the right heel which was dressed with 4x4 gauze and wrapped with kling. There was no documentation the physician was notified.

Review of the Geri-Psych Unit General Orders (physician's orders) 3/14/16 revealed wound care orders as follows: Clean right heel with Microklenz, redress with 4x4 gauze, wrrap with kling gauze and secure with paper tape, daily.

Further review of the Geri Psych RN notes dated 3/15/16, 3/16/16, 3/17/16, 3/18/16, 3/19/16, 3/20/16, 3/22/16, 3/23/16, 3/24/16 and 3/25/16 revealed there was no documentation the wound was assessed or wound care provided.

Review of the RN note 3/21/16 revealed the RN documentated the patient had a "large blister on the right heel". There was no documentation the physician was notified or wound care provided.

An interview was conducted on 6/9/16 at 8:35 AM with Employee Identifier (EI) # 6, Geri Psych Clinical Director and EI # 5, Behavioral Health Program Director who both agreed the wound care management was not done according to the physician's orders.

2. PI # 9 was admitted to the hospital on 3/29/16 with diagnoses including Dementia and Psychosis.

Review of the Geri Psych General Orders 4/11/16 revealed wound care orders, as follows: (Clarification Order) Cleanse right leg, lower anterior, skin tear with Kara clenz and apply Bactroban ointment. Cover with Telfa and wrap with Kerlix (lightly) and secure with paper tape for 5 days, 2 times a day.

Review of the Geri Psych RN notes dated 4/11/16, 4/12/16, 4/13/16, 4/14/16 and 4/15/16 revealed no documentation the wound was assessed and wound care was provided.

An interview was conducted on 6/9/16 at 10:45 AM with EI # 1, Director of Professional Standards who confirmed the above mentioned findings.

Based on review of agency policy, medical records (MR) and interview with administrative staff, it was determined the facility failed to ensure all orders, including verbal or telephone orders given by the attending physician or other practitioners that is acting in accordance to the State law, were authenticated, timed and signed by the ordering physician for 6 of 10 sampled records reviewed.

This affected Patient Identifier (PI) # 1, # 2, # 3, # 5, # 9 and # 10, and had the potential to negatively affect all patients served by the facility.

Findings include:

Health Information Management

Policy: Regarding Orders. Physician Orders for Diagnostic/ Therapeutic/ Treatment

Policy No.: 111.06

Date: 01/01

Only R.N.'s (registered nurse) and L.P.N.s (licensed practical nurse) are allowed to take physician's orders.

The order must be written on the Physician Order Sheet and date, stating whether the order is verbal or a phone order (V.O or P.O.). This may also be documented as telephone order (T.O.) showing the physician's name and nurse signature. The Physican must sign verbal or phone orders within 24 hours.

***

Policy: Physician Assistant's Policies and Procedures

Policy No.: 111.07

Date: 01/03

The physician's assistant may perform only those functions approved by the Medical Staff of Bryan W. Whitfield Memorial Hospital.

Those function are:

...

4. The Physican assistant shall write orders and these orders shall be counter-signed by the supervising physician within 24 hours.



1. PI # 1 was admitted to the hospital on 4/4/16 with primary diagnosis of Altered Mental Status.

Review of the Medical Intensive Care (MICU) General Order form 4/4/16 revealed an order to transfer patient to MICU due to Bilateral Deep Vein Thrombosis. The admitting physician failed to sign the order according to the facility's policy on verbal orders.

An interview was conducted on 6/9/16 at 9:15 AM with Employee (EI) # 1, Director of Professional Standards (DPS) who confirmed the above mentioned findings.

2. PI # 2 was admitted to the hospital on 2/23/16 with diagnoses including Psychosis, Not Otherwise Specified (NOS), Alcohol Dependence and Withdrawal and Rule Out Delirium.

Review of the following Physician's Orders dated 2/23/16, 2/24/16, 2/27/16 , 2/26/16 signed by the Certified Nurse Practitioner (CRNP), 2/27/16, 2/28/16 and 2/28/16, revealed the physician failed to sign the orders written.

An interview was conducted on 6/9/16 at 9:10 AM with EI # 6, Clinical Director (CD), Geriatric Psychiatric Unit. The surveyor asked the CD should the physician sign the HMA ( Home Medication Adminstration/ List) and the CD answered "yes".

3. PI # 3 was admitted to the hospital on 3/7/16 with diagnoses including Probable Exacerbation of Dementia Due to Medical Non compliance and Possibly Also Associated with Urinary Tract Infection and Heart Disease, Hypertension, Diabetes and Stroke by History.

Review of the Medical Intensive Care Unit (MICU) General Order Form dated 3/7/16 revealed the physician failed to authenticate and sign the orders.

Review of the Physician Admission Orders Geriatric Behavioral Health Unit (Geri-Psych) form 3/10/16 revealed the physician failed to sign the admission order form.

Review of the Geri-Psych Physician's Orders dated 3/11/16, 3/12/16 and 3/14/16 revealed the physician failed to sign and authenticate written orders.

Review of the Registered Dietitian (RD) Recommendations 3/14/16 had a notation "must be approved by the Medical Doctor (MD) or CRNP prior to ordering" revealed the physician or the CRNP failed to sign the RD's recommendations.

Review of the Geri-Psych General Orders dated 3/14/16, 3/15/16 and 3/16/16 signed by CRNP and 3/17/16 revealed the physician failed to authenticate and sign the Physican's orders.

Review of the Geri- Psych General Orders dated 3/17/16, 3/21/16, 3/23/16 signed by the CRNP, 3/23/16, 3/25/16 revealed the physician failed to sign and authenticate the written orders.

An interview was conducted on 6/9/16 at 8:35 AM with EI # 5, Program Director and EI # 6, CD who confirmed the staff failed to flag the orders for the physician to sign.

4. PI # 5 was admitted to the hospital's MICU on 3/30/16 with the primary diagnosis of Behavioral Adjustment.

Review of the MICU General Order 4/6/16 signed by the CRNP revealed the physician failed to authenticate and sign the order written by the CRNP.

An interview was conducted on 6/9/16 at 11:00 AM with EI # 1 who confirmed the above mentioned findings.

5. PI # 9 was admitted to the hospital on 3/29/16 with primary diagnosis of Dementia/ Psychosis.

Review of the Geri-Psych General Order Form dated 4/2/16, 4/4/16, 4/4/16, 4/4/16, 4/6/16, 4/8/16 written by the CRNP, 4/8/16, 4/10/16, 4/1/16, 4/13/6 written by the CRNP and 4/15/16 at 11:47 AM, revealed the physician failed to authenticate and sign the Geri Psych orders.

Further review of the Geri Psych General Order Form dated 4/18/16, 4/2016, 4/22/16 written by the CRNP, 4/23/16, 4/24/16, 4/25/16 and 4/28/16 revealed the physician failed to authenticate and sign the Geri Psych orders.

An interview was conducted on 6/9/16 at 10:45 AM with EI # 1, who confirmed the above mentioned findings.

6. PI # 10 was admitted to the hospital on 4/13/16 with diagnoses including Dementia with Behavioral Disturbance and Rule out Delirium Secondary to Medical Condition.

Review of the Geri Psych General Order Form dated 4/18/16, 4/19/16 x 2 orders, 4/19/16, 4/15/16 written by the CRNP x 2 orders and 4/18/16 revealed the physician failed to authenticate and sign Geri Psych orders.

An interview was conducted on 6/7/16 at 4:20 PM with EI # 1 who confirmed the above mentioned findings.

Based on record reviews, interviews and hospital policy, it was determined the facility failed to ensure history and physical, other documents requiring physician's signature are completed according to the hospital Bylaws.

This affected 7 of the 10 closed charts discharged in February 2016, March 2016 and April 2016. They are Patient Identifier (PI) # 1, # 2, # 3, # 4, # 5, # 6, # 9, and # 10

Findings include:

Health Information Management

Completion of Healthcare Records

Policy: Procedure on Handling Incomplete Records

Policy No.: 62.01

Date: 01/03

...

Effective 03/01/2013 per Medical Staff Vote on revision of Bylaws: Physicians shall be notified of all records incomplete fourteen (14) days after discharge. The Physican will then have fourteen (14) days from this notice to complete the records. At the conclusion of this 14 days post notification period, if the records are still incomplete, the physician's privilege to admit patients to the hospital will be automatically suspended. In the event the records are not complete in an additional seven (7) days, all Medical Staff privileges will be revoked.

1. Patient Identifier (PI) # 1 was admitted to the hospital on 4/4/16 with the primary diagnosis of Deep Vein Thrombosis.

Review of the MR 6/8/16 revealed the following documents were not completed according to hospital policy:

a). Psychiatric Discharge Summary dictated on 4/5/16

b). Geriatric Psychiatric (Geri-Psych) Progress Notes dictated on 4/1/16 and 4/2/16.

An interview was conducted on 6/8/16 at 9:15 AM with Employee Identifier (EI) # 1, Director of Professional Services, who confirmed the above mentioned findings.

2. PI # 2 was admitted to the hospital on 2/24/16 with primary diagnosis of Medical Clearance/ Behavioral Unit and on 3/6/16 transferred to Medical Intensive Care (MICU) due to Right Lung Pneumothorax.

Review of the MR 6/8/16 revealed the following documents were not completed according to hospital policy:

a). Psychiatric Evaluation dictated 2/24/16.

b). Psychiatric Discharge Summary dictated 3/2/16.

c). Operative Report dictated 3/28/16.

An interview was conducted on 6/8/16 at 9:00 AM with EI # 1, who confirmed the above mentioned findings.

3. PI # 3 was admitted to the hospital on 3/7/16 admitted to MICU due to Ventricular Tachycardia then transferred to Geri Psych Unit with primary diagnosis Dementia with Acute Psychosis.

Review of the MR 6/8/16 revealed the following documents were not completed according to hospital policy:

a). Psychiatric Evaluation dictated on 3/10/16

b). Psychiatric Discharge Summary dictated on 3/25/16.

An interview was conducted on 6/8/16 at 8:35 AM with EI # 1 who confirmed the above mentioned findings.

4. PI # 4 was admitted to the hospital on 3/26/16 with primary diagnosis of Hallucinations/ Agitated.

Review of the MR 6/8/16 revealed the following documents were not completed according to hospital policy:

a). Psychiatric Evaluation dictated 3/26/16.

b). Psychiatric Discharge Summary dictated 4/15/16.

c). Geri Psych Progress Notes dated 3/8/16, 4/1/16 and 4/2/16.

An interview was conducted on 6/8/16 at 8:15 AM with EI # 1 who confirmed the above mentioned findings.

5. PI # 5 was admitted to the hospital on 3/30/16 with primary diagnosis of Behavioral Adjustment.

Review of the MR 6/8/16 revealed the following documents were not completed according to hospital policy:

a). Geri Psych Progress Note dictated 4/5/16.

An interview was conducted on 6/8/16 at 8:55 AM with EI # 1 who confirmed the above mentioned findings.

6. PI # 9 was admitted to the hospital on 3/29/16 with primary diagnosis of dementia/ Psychosis.

Review of the MR 6/9/16 revealed the following documents were not completed according to hospital policy:

a). Psychiatric Evaluation dictated 3/29/16.

b). Psychiatric Discharge Summary dictated 4/29/16.

c). Geri Psych Progress Notes dictated 3/30/16, 3/31/16, 4/1/16, 4/2/16, 4/4/16, 4/6/16, 4/9/16, 4/8/16, 4/9/16, 4/11/16, 4/12/16, 4/13/16, 4/14/16, 4/15/16, 4/18/16, 4/19/16, 4/20/16, 4/21/16, 4/22/16, 4/25/16, 4/26/16,

d). X ray report of the Left Hand (2 views) dictated 4/4/16.

e). Chest X ray Report dictated 4/25/16.

f). X ray Report of Bilateral Ribs (3 views) dictated 4/18/16,

g) X ray Report Hips (2 views) dictated 4/18/16.

h). Medical Doctor (MD) Daily progress Note dictated 4/2/16.

i). Behavioral Health (B.C.) Progress Notes dictated 4/5/16, 4/9/16 and 4/10/16,

An interview was conducted on 6/9/16 at 10:45 AM with EI # 1 who confirmed the physician failed to sign and authenticate medical documents including those dictated by the certified nurse practitioner.

7. PI # 10 was admitted to the hospital on 4/13/16 with primary diagnosis of Dementia with behavioral Disturbance.

Review of the MR 6/7/16 revealed the following documents were not completed according to hospital policy:

a). Psychiatric Evaluation dictated 4/14/15.

b). Psychiatric Discharge Planning dictated 4/29/16.

c). Geri Psych Progress Notes dictated 4/15/16, 4/18/16, 4/19/16, 4/20/16, 4/21/16, and 4/22/16.

An interview was conducted on 6/7/16 at 3:50 PM with EI # 7, Health Information Management (HIM) Director who concurred with EI # 1 of the above mentioned findings.