HospitalInspections.org

This condition is not met as evidenced by:

Based on record review and staff interview it has been determined that the hospital failed to meet the Nursing Services Condition of Participation relative to providing care in accordance with accepted standards of nursing practice.

Findings are as follows:
1. The hospital failed to provide care according to accepted standards of practice for 1 of 1 patient, Patient ID # 1, relative to the application of hot packs for pain relief. Refer to A 395

2. The hospital failed to supervise and evaluate the nursing care of each patient for 1 of 1 patient, Patient ID # 1, relative to the administration of a treatment (hot packs) without the knowledge of the registered nurse assigned to the patient. Refer to A 395

3. The hospital failed to document in the clinical record the application of a treatment and the resulting injury to Patient ID # 1. Refer to A 395

4. The hospital failed to follow the plan of care for 1 of 1 patient, Patient ID #1, relative to pain management. Refer to A 396.

Based on record review and staff interview it has been determined that the hospital failed to provide care according to accepted standards of practice related to ensuring that a Registered Nurse supervise and evaluate the nursing care provided, documentation of treatments provided and outcomes for 1 of 1 patient reviewed who suffered burns due to improper application of hot packs, Patient ID # 1.

Findings are as follows:

According to the "US Consumer Product Safety Commission" (CPSC) Publication "Avoiding Tap Water Scalds" states in part:
"...the CPSC urges all users to lower their water heaters to 120 degrees Fahrenheit...most adults will suffer third-degree burns if exposed to 150-degree water for two seconds. Burns will also occur with a six second exposure to 140-degree water or with a thirty second exposure to 130-degree water. Even if the temperature is 120 degrees, a five-minute exposure could result in third-degree burns."

1. Record Review for Patient ID #1 revealed s/he was admitted to the inpatient medical unit of Kent County Hospital on 11/3/2022 for a cardiac work up and symptom management, as she presented to the Emergency Room with concerns for progressive lower extremity edema, orthopnea (discomfort when breathing while lying down flat) and dyspnea (difficult or labored breathing) on exertion.

Review of the patient's discharge summary dated 12/4/2022 reveals, "Overnight on 11/23-24 the patient requested heat packs stating [s/he] uses heat packs at home for [his/her] neuropathic pain [pain that occurs if your nervous system is damaged or not working correctly] in [his/her] feet and legs. The next morning, [s/he] unfortunately developed blisters of [his/her] feet and ankles, which were then treated with bandages and gauze."

During an interview with Unit Nurse Manager, Staff B, on 12/27/2022 at 2:10 PM, she revealed that the patient had requested nursing assistant (NA), Staff A to get heat packs. Staff B then stated that when she spoke with NA, Staff A she disclosed that she had made her own heat packs, because the Medline Warm Compresses provided by the hospital do not stay warm. Additionally, Staff A stated that when the patient was being discharged home, the patient's family member informed her that the patient had developed blisters from the heat packs s/he had applied.

During a surveyor interview with Staff A, on 12/29/2022 at approximately 2:15 PM, she revealed that the patient asked her for hot packs. Additionally, she revealed that she used the instant hot water from the kitchen to wet maxi pads and placed them in a sleeve. She further revealed that she was unaware of the temperature of the water she used to make the hot packs for the patient, nor could she recall how long the hot packs were in contact the patients' legs.

Record review of water temperatures that were obtained by a plumber on 12/30/2022 at 5:15 AM from the instant hot water faucet in the kitchen and the hot water faucet of the unit the patient resided on revealed temperatures of 122 Fahrenheit (F) from the hot water faucet, and 165-degree F from the instant hot water.

Review of the patient's skin assessment performed on 11/22/2022 at 4:26 PM prior to Staff A providing him/her with homemade heat packs, states in part; "Some Scattered bruising noted, but otherwise skin is intact".

Additional record review revealed a wound consult was initiated and the patient was seen by a Wound Nurse on 11/29/2022. The record further revealed that the patient was discharged from the inpatient unit on 12/4/2022 and was seen on 12/19/2022 at the Wound Recovery Center, where s/he received treatment for 2nd and 3rd degree burns which required debridement, debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Additionally, the patient had another visit to the Wound Recovery Center on 12/27/2022 where s/he underwent additional debridement of his/her burns.

A review of the "Wound Recovery Center" medical notes state in part:
"Skin; Right dorsal foot with roofed, serous-filled blister measuring 6x3 with pink edges. Scant serous drainage appreciated. Peri wound is edematous. Right anterior ankle with roofed, serous-filled blister measuring 10x4 with pink edges. Scant serous drainage noted. Right posterior heel/Achilles region unroofed blister measuring 5.5x12.5- epidermal layer of skin 60% sloughed off with dermal layer exposed with moist red, yellow, discolored wound bed. Peri wound is dry. Moderate serosanguineous drainage. Left Posterior heel/Achilles region with unroofed blister measuring 6x8.5, epidermis sloughed off approximately 30%, dermal layer exposed with wound bed appears red, maroon, moist, and discolored. Moderated serosanguineous drainage appreciated. Peri wound is dry...Assessment...acquired deep 2nd degree burn blisters to [his/her] bilateral heels/Achilles, right dorsal foot, and right anterior ankle region. "

During a surveyor interview with the Director of Risk Management on 12/27/2022 at approximately 12:30 PM, she revealed that homemade heat packs were applied to the patient's lower extremities by Staff A and that Staff A did not inform nursing staff that she was doing so.

During a surveyor interview with the Interim Director of Nurses, and the Director of Risk Management on 12/29/2022 at 8:30 AM, she acknowledged that Staff A should have communicated with nursing prior to providing hot packs to the patient.

2. Record review of the hospital's job description for Nursing Assistants, dated 1/2020, states in part, Primary Function.
" ...Work under the direct supervision of a Registered Nurse and observe all hospital policies and procedures.
Responsibilities 1. Provide general patient care and perform routine treatments and procedures as directed by the Registered Nurse."


During a surveyor interview with the Director of Risk Management on 12/27/2022 at approximately 12:30 PM, she revealed that the heat packs provided to Patient ID #1 and the subsequent burns' s/he developed, were applied by the NA Staff A and that the nurse assigned to the patient, Staff C, was not aware nor did she authorize that Staff A to apply the heat packs to the patient's lower extremities.

Record review for Patient ID #1 failed to reveal evidence of physician's orders for heat packs as a treatment for the patient.

During a surveyor interview with Staff D, the patient's physician, on 12/28/2022 at 2:30PM, he stated that he was not aware that the patient had been provided with hot packs until s/he had developed blisters. Additionally, he revealed that he did not order hot packs as treatment for the patient. Additionally, he stated he would not expect a patient be provided with a hot pack without an order.

During a surveyor interview on 12/29/2022 with NA Staff A, at approximately 2:15 PM, she revealed that the patient had asked for hot packs, so she made them. She revealed that she used the instant hot water from the kitchen to wet the pads and placed them in an ice sleave. She acknowledged that she did not check with the nurse prior to providing the patient with the homemade hot packs, nor was she aware the patient had diabetic neuropathy.

During a surveyor interview with the Director of Risk Management, along with the Nurse Manager Staff B, on 12/27/2022 at approximately 2:10 PM, they revealed that per hospital policy, heat packs are a "nursing measure" and do not require a physician's order. Additionally, they acknowledged that the nursing assistant applied the "home made" heat packs without consulting with the nurse first which resulted the patient sustaining 2nd and 3rd burns to his/her lower extremities. They further acknowledged that nursing assistant, Staff A, acted outside of her job description.

3. Record review for Patient ID #1 lacked evidence of documentation for the application of hot packs on 11/23/2022.

During a surveyor interview with the Risk Manager on 12/27/2022, at approximately 12:30 PM, she revealed that upon learning of the incident, she had interviewed the nurse, Staff C, who informed her that nursing assistant Staff A had applied the hot packs. Additionally, the Risk Manager was unable to provide evidence that Patient ID #1's record contained documentation of the application of the heat packs and acknowledged that the nurse should have documented that the patient was provided with the hot packs.

Based on record review and staff interview it was determined that the hospital failed to keep a current nursing care plan which meet the needs of the patient for 1 of 1 patient, Patient ID #1, relative to edema, and blisters on the patient's lower extremities.

Findings are as follows:

Review of the hospital policy "Patient Assessment, Reassessment, and Discharge Documentation" dated 10/9/2020 states in part:

Policy: It is the policy of Kent Hospital that all patients assigned a status of inpatient or observation will be assessed by an RN/LPN according to the following guidelines. The RN/LPN may delegate elements of assessment and reassessment to a Nurse Assistant that do not require assessment, evaluation or analysis such as vital signs, height and weight.

...Procedures:
"C. Interdisciplinary Plan of Care

An individualized plan of nursing care shall be developed by the RN. It shall reflect current nursing standards, shall be consistent with the medical plan and shall promote patient's well-being and knowledge of self- care. This plan shall include Problem Identification, Realistic goals mutually set with patient/family, interventions/Patient Family Teaching. This plan shall be updated as needed.

Review of the medical record for Patient ID #1, revealed a nursing assessment dated 11/23/2022, which states in part ..."3+ pitting edema noted"

Review of an Interdisciplinary Plan of Care dated 11//24/2022, and 11/26/2022, lists concerns/issues as:

"Cardiovascular, Shortness of Breath and Therapies/Mobility" .
The Plan of Care lacks documentation relative to burns which the patient developed on 11/23/2022 from the application of the heat packs.

During a surveyor interview with the Director of Risk Management on 12/27/2022, at approximately 3:00 PM, she was unable to produce evidence that the Plan of Care was updated to include the issue of the burns that the patient developed on 11/23/2022.