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Based on record review and interview, the facility failed to follow their policy and procedure for grievances for 1 (#1) of 3 patients reviewed for grievances out of a total of 10 sampled patients, resulting in the potential for less than optimal outcomes and the potential for reoccurrence. Findings include:

A review of the closed medical record for patient #1 was conducted with Staff P on 4/11/18 at 1130. Director of Nursing Staff B and Nurse Manager Staff H were also present for the medical record review at that time. Per record review patient #1 was admitted to the facility on 2/21/17. A review of the patient's nursing admission assessment dated 2/21/17 at 2130 documented the patient had a healed stage 1 (intact skin that is non-blanchable) pressure sore to both buttocks on admission. Further review review of the medical record revealed on 2/28/17 at 0823 the patient was observed with a skin tear to the right knee.

On 4/11/18 at 1145 when queried Staff H explained she recalled that it was brought to her attention by a family member that patient (#1's) leg was stuck in a side rail. Staff H recalled she observed the patient's leg in contact with the side rail. She said that she did not recall if the patient's leg was actually caught in the side rail. When asked to explain how she responded to the family members concern or if she recalled repositioning or assessing the patient's leg for injury she said she she did not. Staff H said she called for her nursing staff to come in to assist and assess the patient. She said 2 nurse's were called to the room to assist the patient with repositioning. When asked to explain if she looked at the patient's leg for any injury after her staff responded, she said yes. She said the patient's right knee was red. When asked to explain if the patient required any treatment for the right knee injury Staff H said she thought her nurse's followed up with the medical doctor to address the patient's condition.

When asked to explain if an incident/accident was documented she said she did not. Staff H explained she assumed the nursing staff who observed the injury would have documented the concern. When asked to explain if there was an investigation conducted regarding the aforementioned concern, Staff H said there was not.

On 4/11/18 at 0945 an interview was conducted with the Director of Risk Management Staff N and Patient Relations Specialist Staff O complaint and grievance logs were reviewed. There were no complaints or grievances logged for the patient #1. At that time both Staff N and Staff O said we did not document any complaints or grievances for patient #1.

At that time Staff O said she recalled meeting with patient #1's wife on 2 occasions in response to her wanting to meet with the Administrator regarding concerns with patient #1's care. Staff O explained as a result of the concerns having to do with care, our department would be the first to address those concerns. Staff O said the first encounter was in the lobby. She said the patient's wife said "hospice was being pushed on her for patient #1's treatment plan." Staff O said the second encounter occurred a couple of days later in the lobby. Staff O said the Nurse Manager Staff H was also in the lobby. Staff O said concerns were identified that the patient's (#1's) knee was found wedged between a side rail and a mattress with an injury. Staff O was asked to explain why there was no evidence that documented the complaint/grievance. Staff O said she did not think the concern regarding "hospice" was a grievance.

On 4/11/18 at 1053 Staff N stated, "There is nothing documented for patient #1". She said we should have. We always follow through with patient/family concerns. Staff N said she recalled meeting with and speaking with the patient's wife during his hospitalization. Concerns were identified about the patient's right knee being injured by the side rail. Staff N stated, "I explained that I would call her back in response to her concerns." Staff N said recalled leaving a voice mail with the patient's wife regarding follow-up in 11/2017.

Additionally, Staff N provided a letter addressed to the patient's wife dated 1/12/2018. The letter was in response to written concerns addressed to the president of the facility that outlined a "series of incidents that transpired during the patient of concerns (#1's) stay at the facility."
The letter drafted by Staff N on 1/12/2018 directed the patient's wife to "place in writing what you are seeking and what unresolved expectations that you may have." However, there was no further evidence that documented facility staff followed their policy and procedures for complainants and grievances.

A review of the facility's policy titled, "Family Complaint and Grievance Process" PolicyStat ID: 2397625 dated last revised 04/2016 documented:
Policy:
"...B. The hospital must inform the patient and/or the patient's representative (as allowed under State law) of the hospital's grievance process, including whom to contact to file a grievance...C. The hospital must review, investigate, and resolve each patient's grievance within a reasonable time frame....D. All patient grievances must be responded to in writing within 7 (seven) working days. The final response letter must include the substance of the grievance, the steps taken to investigate the grievance, the results of the investigation and the date of completion. The response must also include the Patient Relations Advocate's name and telephone number.
1. In those situation that a resolution cannot be reached in that time frame, a letter will be sent indicating the anticipated date of resolution. Another letter will be sent to notify the patient or the patient's representative of the resolution, once completed.

Based on observation, interview and record review the facility failed to ensure nursing staff adhered to professional standards as evidenced by:
(1) Failed to ensure nursing staff notified the physician of changes in skin integrity and consistently assessed and implemented interventions to promote healing for patient change in skin condition for 1 patient (#1) of 3 patients
(2) Failure to ensure nursing staff developed a plan of care that addressed intravenous therapy (IV) management for 2 patients (#2 and #6); failure to update a "Skin" care plan that addressed changes in skin conditions for 1 (#1) of 4 patients reviewed with skin conditions and failed to develop a plan of care that addressed urinary catheter management for 2 (#'s 2 and 6) of 2 patients reviewed with altered urinary elimination
(3) Failure to ensure nursing staff performed intravenous access dressing changes per policy for 1 (#6) of 3 patients observed with intravenous access; wasted narcotic medications per policy and procedure for 1 (#6) of 1 patients observed during medication pass; failure to ensure nursing staff labeled and dated IV tubing and IV solutions in current use for 2 (#2 and #6) of 3 patients reviewed with intravenous therapy resulting in the potential for less than optimal outcomes for all patients. Findings Include:

See specific tags:
A-392: Failed to ensure nursing staff notified the physician of changes in skin integrity and consistently assessed and implemented interventions to promote healing.
A-396: Failure to update a nursing care plan that addressed changes in skin condition. Failure to develop comprehensive care plans for intravenous therapy management and altered urinary elimination.
A-409: Failure to label and date intravenous solutions and IV tubing in current use and perform IV dressing changes per policy and procedure. Failure to ensure staff wasted intravenous narcotic medications in accordance to policy and procedure.

Based on record review and interview the facility failed to ensure nursing staff notified the physician of changes in skin integrity and consistently assessed and implemented interventions to promote healing for patient change in skin condition for 1 patient (#1) of 3 patients reviewed for skin conditions out of a total of 10 sampled patients resulting in the potential for less than optimal outcomes.
Findings include:

A review of the medical record for patient #1 was conducted with Staff P on 4/11/18 at 1130. Staff B and Staff H were also present for the medical record review at that time. Per record review patient #1 was admitted to the facility on 2/21/17. A review of the patient's nursing admission assessment dated 2/21/17 at 2130 documented the patient had a healed stage 1 (intact skin that is non-blanchable) pressure sore to both buttocks on admission. Further review review of the medical record revealed on 2/28/17 at 0823 the patient was observed with a skin tear to the right knee. There was no further description that documented the size of the skin tear, the characteristics of the skin tear or if any drainage was observed. There was no evidence that documented the medical doctor was notified of the skin tear. There was no evidence that documented any orders were obtained to promote wound healing and/or to protect the skin to prevent further skin breakdown.

A review of skin assessments were reviewed a revealed the following:

A review of a skin assessment date 3/1/18 at 0830 documented a skin tear was observed on the patient's right knee. However, there was no further description that documented the size of the skin tear, the characteristics of the skin tear or if any drainage was observed. There was no evidence that documented the medical doctor was notified of the right knee skin tear. There was no evidence that documented any orders were obtained to promote wound healing and/or to protect the skin to prevent further skin breakdown or injury.

On 3/3/18 at 2014 per skin assessment a dry dressing was applied to the patient's right knee lesion. There was no further description that documented the size of the skin lesion, the characteristics of the lesion or if any drainage was observed. Additionally, there was no evidence that documented the medical doctor was notified of the right knee lesion. There was no evidence that documented any orders were obtained to promote wound healing and/or to protect the skin to prevent further skin breakdown.

Further review of the patient's twice per day skin assessments dated 3/4/17 through 3/9/17 (discharge date) documented the patient's right knee lesion was present. However, there was no evidence in the medical record that documented the patient's wound was being consistently addressed to promote healing.

A review of the patient's discharge instructions dated 3/9/17 only addressed the patient's high blood pressure and medical doctor follow-up appointments. There were no instructions documented for the patient's right knee lesion documented on the discharge instructions.

On 4/11/18 at 1145 when queried Staff H explained she recalled that it was brought to her attention by a family member that patient (#1's) leg was stuck in the side rail. Staff H recalled she observed the patient's leg in contact with the side rail. She said that she did not recall if the patient's leg was actually caught in the side rail. When asked to explain how she responded to the family members concern or if she recalled repositioning or assessing the patient's leg for injury she said she she did not. Staff H said she called for her nursing staff to come in a assess the patient. She said 2 nurse's were called to the room to assist the patient with repositioning. When asked to explain if she looked at the patient's leg for any injury after her staff responded, she said yes. She said the patient's right knee was red. When asked to explain if the patient required any treatment for the right knee injury Staff H said she thought her nurse's followed up with the medical doctor to address the patient's condition.

Staff H was asked if the 2 nurse's who were called to assist with repositioning patient #1 were available for interview. Staff H said no they were not. She said one nurse was on a medical leave. She said she could not recall who the other nurse was. Staff H said neither staff were new nurses.

On 4/11/18 at 1200 when queried Staff B confirmed the documentation for wound assessment and follow up care and treatment was lacking. A review of the facility's policy for skin titled "Pressure Ulcer Prevention and Management" PolicyStat ID; 3149062, dated last revised on 5/2017 documented:
"Documentation:
1. Dates and times
2. Assessments/skin appearance
3. Location
a. Identify specific location
4. Stage
5. Size
a. Include length, width and depth measurements in centimeters. Include undermining
and tunneling as appropriate.
6. Drainage the amount, color and odor of drainage...
7. Character of wound
8. Intervention/Dressing Change
9. Patient's Response
10. Patient/family teaching and level of understanding on Wound Assessment Form under Wound education. Include written literature given to patient/family...".

Based on observation, interview and document review, the facility failed to ensure nursing staff updated the plan of care and implemented individualized interventions that addressed changes in skin condition for 1 (#1) of 3 patient's reviewed with alterations in skin integrity out of a total of 10 sampled patients and the facility failed to ensure nursing staff developed a comprehensive care plan that addressed Intravenous (IV) therapy and urinary catheters for 2 (#'s 2 and 6) of 3 patients reviewed for IV therapy and urinary catheter care resulting in the potential for the less than optimal outcomes for the patients. Findings include:

A review of the closed medical record for patient #1 was conducted with Staff P on 4/11/18 at 1130. The Director of Nursing Staff B was also present for the medical record review at that time. Per record review patient #1 was admitted to the facility on 2/21/17. A review of the patient's nursing admission assessment dated 2/21/17 at 2130 documented the patient had a healed stage 1 (intact skin that is non-blanchable) pressure sore to both buttocks on admission.

A review of the patient's (#1's) care plan for maintaining skin integrity dated 2/23/2017 documented the following interventions:
"Reminder: Support surface selection keep turning at least every 2 hours and/PRN (as needed) keep heels off loaded keep pressure devices off skin incontinence management nutrition management."

Further review review of the medical record revealed on 2/28/17 at 0823 the patient was observed with a skin tear to the right knee. There was no further description that documented the size of the skin tear, the characteristics of the skin tear or if any drainage was observed. There was no evidence that documented the medical doctor was notified of the skin tear. There was no evidence that documented any orders were obtained to promote wound healing and/or to protect the skin to prevent further skin breakdown.

A review of skin assessments for patient (#1) were reviewed and revealed the following:

A review of a skin assessment date 3/1/17 at 0830 documented a skin tear was observed on the patient's right knee. However, there was no further description that documented the size of the skin tear, the characteristics of the skin tear or if any drainage was observed. There was no evidence that documented the medical doctor was notified of the right knee skin tear. There was no evidence that documented any orders were obtained to promote wound healing and/or to protect the skin to prevent further skin breakdown.

On 3/3/17 at 2014 per skin assessment a dry dressing was applied to the patient's right knee lesion. There was no further description that documented the size of the skin lesion, the characteristics of the lesion or if any drainage was observed. Additionally, there was no evidence that documented the medical doctor was notified of the right knee lesion. There was no evidence that documented any orders were obtained to promote wound healing and/or to protect the skin to prevent further skin breakdown.

On 3/8/17 at 2100 right knee lesion note. No further description of wound characteristics or treatment.
On 3/9/17 at 0915 (date of discharge) right knee lesion noted. No further description of wound characteristics or treatment.

However, there was no evidence in the medical record that documented the patient's wound was being consistently addressed to promote healing. There were no updates to the patient's (#1's) altered skin integrity plan of care.

On 4/10/18 at approximately 1100 patient #2 was observed in bed while accompanied by Patient Care Technician Staff E. The patient was hard of hearing and was visually impaired. The patient was oriented to person at that time. Staff E explained she had performed morning (am) care. A drainage bag was observed with reddish colored drainage. Staff E said the patient had been pulling at his catheter earlier. The patient was observed restrained in bilateral wrist restraints and bilateral hand mitts. An IV pump with IV solutions labeled (D 5.45) with approximately 500 milliliters were observed in the patients room. Staff E said she did not know if the patient had an IV access.

On 4/10/18 at 1110 while accompanied by Registered Nurse Staff F patient #2 was observed for a skin assessment observation. When queried regarding the IV solutions Staff F said "I disconnected him. Therapy was in ambulating him I will reconnect him." When asked to explain why the IV tubing was not labeled Staff F stated, "The IV was already connected and infusing this morning. I didn't spike the bag. I always get a new set up and label whenever I spike a new bag." Staff F was observed as she removed the right mitt and right soft wrist restraint from patient #2's hand. A peripheral IV was observed heplocked in the patient's right anterior hand. Staff F was overheard as she stated, "This is not a good site for the heplock. We can't see the site. I'll have to call the doctor." At that time an indwelling urinary catheter was observed in place draining reddish color drainage.

On 4/10/18 at 1133 a review of the medical record for patient #2 was conducted. There was no care plan for the patient IV access or catheter care documented in the medical record to assist nursing staff in goal directed care.

On 4/10/18 at 1500 patient #6 was observed for wound care observation that was performed by Wound Care Nurse Staff S. Patient #6 was alert with confusion and agreeable to the wound care observation. An indwelling urinary catheter was observed intact draining amber colored drainage.

On 4/10/18 at 1520 patient #6 was observed in bed while accompanied by Staff T. A right antecubital midline IV catheter was observed. There was no legible date on the dressing. There were no labels on the IV tubing or IV solutions labeled D 5.45. The pump was set at 75 ml/hour. Staff T was overheard as she said it looks like the date had been written it's just not legible.

On 4/11/18 at 1330 a review of the medical record for patient #2 and #6 was conducted with Staff P and Staff B. There were no care plans in the medical record that addressed the patient IV therapy care needs or urinary catheter needs for either patient. At that time Staff B confirmed both patient's should have had a care plan for IV therapy and catheter care.

On 4/11/18 at 1400 a review of the facility's policy titled "Care Planning" PolicyStat ID: 3174446 dated last revised 1/2017 documented:
"Policy:
D. Plan of Care Review:
1. The plan of care should be reviewed, at least daily by an RN to determine progress toward goals. It should be revised as necessary as a result of ongoing assessment and interdisciplinary rounds, and may include case management, nutritional services, physician, rehabilitation services, pharmacy, pastoral services, etc.
F. Planning Patient Care:
...2b. Interventions...i. As needs of the patient change and new patient problem(s) or clinical variances are identified, the plan should be updated."

Based on observation, interview and document review the facility failed to ensure nursing staff:
1) assessed and changed intravenous (IV) catheter access dressing per policy and procedure for 1 (#6) of 3 patients reviewed for intravenous therapy.
2) labeled and dated Intravenous (IV) medication solutions and IV tubing in current use for 2 patients (#'s 2 and 6) of 3 patients observed during observations.
3) the facility failed to ensure nursing staff wasted IV narcotic medications according to policy and procedure for 1 (#6) of 2 patients observed during medication pass observations.
resulting in the potential for less than optimal outcomes. Findings include:

On 4/10/18 at approximately 1100 patient #2 was observed in bed while accompanied by Patient Care Technician Staff E. The patient was hard of hearing and was visually impaired. The patient was oriented to person at that time. Staff E explained she had performed morning (am) care. The patient was restrained in bilateral wrist restraints and bilateral hand mitts. An IV pump with IV solutions labeled (D 5.45) with approximately 500 milliliters were observed in the patients room. Staff E said she did not know if the patient had an IV access.

On 4/10/18 at 1110 while accompanied by Registered Nurse Staff F patient #2 was observed for a skin assessment observation. When queried regarding the IV solutions Staff F said "I disconnected him. Therapy was in ambulating him I will reconnect him." When asked to explain why the IV tubing was not labeled Staff F stated, "The IV was already connected and infusing this morning. I didn't spike the bag. I always get a new set up and label whenever I spike a new bag." Staff F was observed as she removed the right mitt and right soft wrist restraint from patient #2's hand. A peripheral IV was observed heplocked in the patient's right anterior hand. Staff F was overheard as she stated, "This is not a good site for the heplock. We can't see the site. I'll have to call the doctor."

On 4/10/18 at 1130 Staff H was queried regarding how often IV tubing was to be changed and if IV tubing and solutions should be labeled with date and time of when used. Staff H said IV tubing change times may vary. Staff H said all tubing should be labeled or discarded after use time.

On 4/10/18 at 1500 patient #6 was observed for wound care observation that was performed by Wound Care Nurse Staff S. Patient #6 was alert with confusion and agreeable to the wound care observation. Patient #6 was overheard as he grumbled with discomfort with repositioning. Staff S explained she would have his nurse medicate him with something for pain.

On 4/10/18 at 1520 Staff T was observed with a vial of morphine labeled 4 mg/1 ml (4 milligrams per 1 milliliter). Staff T explained the patient was getting 2 mg. Staff T was observed as she administered the 2 mg of Morphine IV push to patient #6. Patient #6 was observed with a right antecubital midline IV catheter. There was no legible date on the dressing. There were no labels on the IV tubing or IV solutions labeled D 5.45. The pump was set at 75 ml/hour. Staff T was overheard as she said it looks like the date had been written it's just not legible.

Staff T was observed with the remainder of the vial 0.5 ml of Morphine. Staff T said, "I already wasted it." She said (name of other nurse) Staff U witnessed me waste it when I removed it from the "Pyxis" (automated medication dispensing system). Staff T was asked to explain how the morphine was witnessed as wasted when she was holding the vial containing 2 mg/0.5 ml of Morphine. Staff T said that's the only way it can be wasted. She said I have sign it out first. I can't discard the vial. I have to take the vial to the patient's room and scan the vial again. Staff T said the second nurse witnessed that I took it out and she signed off as well that the 2 mg was wasted. Staff T was observed as she discarded the vial containing 2mg of Morphine in a sharps container in the medication room on 4/10/18 at 1540.

On 4/10/18 at 1600 Staff U was asked to explain how she witnessed Staff T waste 2 mg of morphine injection. According to Staff U, she was with Staff T as she removed the 4 mg of morphine vial from the Pyxis. She said the patient's (#6) dosage was for 2 mg. She said therefore 2 mg had to be wasted. When asked to explain how she witnessed Staff T waste the remaining 2 mg Staff U said she didn't because Staff T still had the vial.

On 4/11/18 at 0845 a review of the facility's policy titled "Peripheral Access Device sand Intravenous (IV) Therapy, Care and Maintenance" PolicyStat ID: 2727329 dated last revised on 9/2016, documented:
Peripheral IV administration:
C. IV administration tubing for continuous infusions is changed every 96 hours and every 24 hours for intermittent infusions.

On 4/11/18 at 0900 a review of the facility's policy titled "Midline Venous Catheter" PolicyStat ID 1528773 dated last revised on 7/2015 documented:
Maintenance
D. 5. The dressing should be changed when loose soiled, and at least every 7 days using a midline catheter dressing kit and appropriate securement devices for the line.

On 4/11/18 at 0915 a review of the facility's policy titled "PYXIS" Medication Returns and Waste" PolicyStatID 3162749 dated last revised on 1/2017 documented:
B. WASTES:
3. Two qualified personnel will be required to waste a controlled substance medication. The second qualified person will serve as a witness to the waste to prevent diversion.


On 4/11/18 at 1100 a review of the medical record for patient # 6 was conducted with Assistant Clinical Lead Nurse Staff P Staff B was also present for the medical record review at that time.

Per record review patient #6 was admitted to the facility on 3/31/18. Further review of the medical record documented a Midline Venous Catheter was inserted on 4/1/18. A review of nursing notes, medication admission records, treatment records and physicians orders revealed there was no evidence that documented the dressing for the Midline Venous Catheter had been changed after 4/1/18. At that time when queried regarding who was responsible for changing the IV dressing for patient #6 Staff B said only the specialty team members who inserted those type of lines. Staff B said the dressings were changed every 7 days and that included coverage 24/7. Staff B confirmed the patient's IV dressing should have been changed on 4/8/18. However, Staff B was unable to explain why there was no evidence in the medical record that documented the patient's IV dressing had been changed since 4/1/18.