HospitalInspections.org

Based on document review and interview, the facility failed to ensure nursing care was provided according to policy for ten of ten patient medical records reviewed (#1- #10).

Findings included:

1. The facility policy "Wound Care", effective August 2014, indicated, "A. All patients admitted to [geriatric unit] will be assessed on admission for any types of wounds. B. Appropriate prevention and reduction procedures will be implemented at time of admission. C. All interventions will be documented in the nursing assessment and nursing notes, and a treatment plan will be created. ...F. Nutritional assessment and management to ensure the diet contains nutrients adequate to support healing. ...Weekly weights are conducted routinely. G. Patients will be monitored for incontinence care, pressure reduction (ie, position changes every 2 hrs)."

2. The facility policy "Vital Signs and Weight", last revised August 2013, indicated, "All patients are weighed on admission; further weights will be done on a weekly basis on Friday unless otherwise specified by a physician order. Procedure: 1. Vital signs and weight are taken by the RN [Registered Nurse], LPN [Licensed Practical Nurse], or MHT [Mental Health Tech]. 2. Vital signs and weights are monitored by the nurse, recorded in the medical record, and reported to the physician as appropriate."

3. The facility policy "Fall Prevention", last reviewed August 2013, indicated, "3. Universal Fall Precautions will be implemented for all patients- regardless of risk assessment. ...Offer toileting minimum every 2 hours and prn as needed."

4. Review of the following medical records (MR) indicated the following:
a. Patient #1 was admitted on 03/18/15, a Wednesday, and was assessed on admission as a risk for falls. Patient #1's MR lacked documentation that the patient was offered toileting every 2 hours. The MR also lacked documentation of the weekly Friday weight on 03/20/15.
b. Patient #2 was admitted on 03/18/15, a Wednesday, and was assessed on admission as a risk for falls. Patient #2's MR lacked documentation that the patient was offered toileting every 2 hours. The MR also lacked documentation of the weekly Friday weight on 03/20/15.
c. Patient #3 was admitted on 03/20/15 and was assessed on admission as a risk for falls. Patient #3's MR lacked documentation that the patient was offered toileting every 2 hours.
d. Patient #4 was admitted on 03/23/15 and was assessed on admission as a risk for falls. Patient #4's MR lacked documentation that the patient was offered toileting every 2 hours.
e. Patient #5 was admitted on 03/20/15 and was assessed on admission as a risk for falls. Patient #5's MR lacked documentation that the patient was offered toileting every 2 hours.
f. Patient #6 was admitted on 03/19/15 and was assessed on admission as a risk for falls. Patient #6's MR lacked documentation that the patient was offered toileting every 2 hours.
g. Patient #7 was admitted on 02/17/15 and was assessed on admission as a risk for falls. Patient #7's MR lacked documentation that the patient was offered toileting every 2 hours.
h. Patient #8 was admitted on 01/09/15 and was assessed on admission as a risk for falls. Patient #8's MR lacked documentation that the patient was offered toileting every 2 hours.
i. Patient #9 was admitted on 01/09/15 and was assessed on admission as a risk for falls. Patient #9's MR lacked documentation that the patient was offered toileting every 2 hours.

5. Patient #10 was admitted from an extended care facility on 01/20/15 due to increased confusion and aggression with a diagnosis of Dementia, Alzheimer's type. The patient also was admitted with diarrhea and scabies. The admission nursing skin assessment indicated the patient's bottom and scrotum were red and sore, there was a scratch on the left knee, and there was a rash on the belly, shoulder blades, and under the arms. The initial assessment indicated the patient was a fall risk, and the record lacked documentation of an admission weight. The patient was considered at risk for falls throughout the hospitalization and had every 15 minute checks performed by staff and had one on one monitoring after the fall on 01/23/15. Nursing entries from 01/22/15 on the Master Treatment Plan indicated the patient was at risk for falls and for impaired skin integrity, but did not identify any interventions to prevent any skin problems. On 01/25/15, nursing documentation indicated when the patient was being cleaned after a bowel movement, a dime size open red area was noted on the buttocks/coccyx. It could not be determined by documentation that the patient was offered toileting every two hours and as needed as specified in the fall prevention policy. Documentation indicated the patient ate fairly well on 01/21/15 and fair on 01/22/15, but ate poorly, very little, or refused meals and snacks between 01/23/15 and 01/29/15. The treatment team, which was comprised of a physician, a nurse, a social worker, and a therapy assistant, met daily Monday through Friday and discussed each patient, but the notes for patient #10 lacked any documentation of the lack of oral intake and poor appetite or the possible need for a nutritional assessment. No weights were documented for patient #10 until 01/30/15, the day of discharge.

6. At 11:20 AM on 03/26/15, staff member #3, a Mental Health Tech and Certified Nursing Assistant, indicated the patients usually received showers every other day and the skin would be checked with the nurse notified of any problems. He/she indicated all of the patients were offered toileting at least every two hours or more often as necessary. When questioned about documentation of this, staff member #3 indicated it would only show up on the Close Observation Form if it occurred exactly on a 15-minute time frame. He/she explained that if the patient had been checked at 10:15 AM, then was taken to the bathroom or changed at 10:21 AM, this would not be documented. He/she indicated patients were assisted to shift their weights or were propped with pillows while they were sitting up.

7. At 11:50 AM on 03/26/15, staff member #4, the Lead Mental Health Tech and Certified Nursing Assistant, indicated all staff were taught to reposition and assist with toileting every two hours, but confirmed the Close Observation Forms did not necessarily reflect that process. He/she indicated weights were obtained on admission , then every Friday, and they were usually obtained by the techs.

8. At 2:10 PM on 03/26/15, staff member #6, a Mental Health Tech and Certified Nursing Assistant, was questioned on the unit regarding documenting turning and toileting of patients. He/she explained the same procedure as staff member #3 in that the turning or toileting would only be recorded on the form if it occurred exactly at the 15-minute time block.

9. At 2:15 PM on 03/26/15, staff member #5, a Licensed Practical Nurse, was interviewed and indicated if all of the admission assessments could not be done due to the patients condition, that would be passed along to the next shift to complete. He/she indicated the weights were done by the techs, but it was the charge nurse's responsibility to ensure everything was done. He/she indicated nursing staff should notify the physician if the need for a nutritional screening was identified.

10. At 4:00 PM on 03/26/15, staff member #2, the Chief Nursing Officer, indicated both the psychiatrist and the medical physician saw each patient daily. He/she indicated the nurse would do a nutritional screening on admission which would trigger a consult with the dietician if applicable. He/she indicated the treatment team discussed each patient daily on week days and all issues with the patient should be brought to the physicians' attention. He/she indicated staff just started adding medical problems to the care plans in the last few months and there were still some issues with entering the necessary information. He/she confirmed the current documentation on the Close Observation Forms made it unable to determine when the patients were turned or assisted with toileting. He/she also confirmed the medical record findings of lack of weights for patients #1, #2, and #10 and the lack of any documentation by the treatment team regarding the lack of adequate nutrition for patient #10. He/she indicated patients #1 and #2 should still have been weighed on Friday even though they were just admitted the previous Wednesday.