HospitalInspections.org

Based on observation, interview and record review the facility failed to:


a. evaluate patients in the area of skin breakdown/bruising, provide pain medication timely, assess pain levels, assess development of edema, assess physical capabilities and changes in condition in 4 of 14 patients reviewed for assessment (4, 5, 8 and 10).
Refer to A0395 for additional information.

b. ensure nursing prepared thickened liquids as planned in 1 of 1 patients with swallowing difficulties (#5).
Refer to A0396 for additional information.

c. ensure pain medication was administered as ordered by the physician in 1 of 14 sampled patients (#8).
Refer to A 0405 for additional information.

Based on observation, interview and record review the facility failed to evaluate patients in the area of skin breakdown/bruising, provide pain medication timely, assess pain levels, and assess changes in development of edema, assess physical capabilities and changes in condition in 4 of 14 patients reviewed for assessment (4, 5, 8 and 10).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

Review of an admission "Assessment Report" dated 02/03/2014, 4:30 p.m., revealed Patient #5 was a 76 year old female who presented with chief complaint of shortness of breath. According to the nursing "Assessment Report" dated 02/03/02014, Patient #5 had a skin tear to the right forearm with steri strips in place. She had a Braden Score of 12 (tool used to measure pressure sore risk). Patient #5 was incontinent and needed assistance with bed mobility. There was no edema noted and she was on 3 liters of oxygen per nasal cannula with clear breath sounds.
Review of a nursing "Assessment Report" dated 02/04/2014 revealed no documented assessment of the presence of edema. The next documented assessment on edema was on 02/05/2014 at 7:15a.m, 2 days after admission. This assessment indicated there was no edema present, but Patient #5 had coarse rhonchi lung sounds.
According to a "Medication Administration Record" dated 02/05/2014, at 8:58 a.m., Patient #5 was given a STAT (immediate) dose of the diuretic Lasix 20 milligrams.
The next documented assessment on edema was 2/06/2014, at 7:15 a.m. The patient had 1 plus mild pitting edema, slight indentation to the right hand. On the same assessment was documentation the edema to the right hand was non-pitting.
On 02/08/2014, at 8:10 a.m., (2 days later) there was documentation of "bruising noted to bilateral arms with edema. Elevated on pillows." There was documentation of the right and left hand having edema. There was no assessment of how much edema existed.
On 02/09/2014, at 8:05 a.m., there was 1 plus mild pitting edema, slight indentation to the left arm. There was 2 plus moderate pitting edema to the right arm and hand.
On 02/10/2014, at 7:35 p.m., there was edema noted to the right arm but another assessment at the same time noted Patient #5 had no edema.
On 02/11/2014 and 02/12/2014, there was documentation of the right arm being edematous, but no mention of the left arm.
During an observation on 02/13/2014, at 10:15 a.m., Patient #5 was found with the following:

*In bed lying in stool which was pooled underneath her. Her abdomen was distended, food particles were scattered all over the top bed covering and she was complaining of chest pain at a level of 10 (0 no pain and 10 worst pain possible).
*Right upper arm had pitting edema, an approximate 3 inch skin tear with steri-strips, above that was a purple ecchymosis, and beneath the skin tear near the elbow the skin was red.
*Left upper arm had pitting edema with dark red scattered ecchymotic areas.
* Left inner left buttock with three open sores approximate 1.0 centimeters in size with red/pink wound beds. Inside the left inner leg were two more open sores approximate 1.0 centimeters in size with red wound beds. Both inner legs and peri- area were red and excoriated.

During an observation on 02/13/2014, at 10:47 a.m., (over 30 minutes later), Staff #6 administered pain medication to Patient #5.
Review of the nursing "Communication Report" for the day revealed Patient #5 had a diagnosis of congestive heart failure, chronic pulmonary obstructive disease. There was no documentation of the skin breakdown on the buttock, abdominal distention or the edema.
During an interview on 02/13/2014, after 11:00 a.m., Staff #3 revealed the "Communication Report" was used by nursing to document changes and keep up with what was going on with the patient. She confirmed there was assessment of the patient's status.

Review of a "Medication Administration Record" revealed Patient #5 received the pain medication Hydrocodone 10/325 milligrams at the following times:
02/04/2014, at 8:52 p.m.- (The nursing "Assessment Report" dated 02/04/2014 revealed at 7:32 p.m., Patient #5 had pain at the back of her head. There was no assessment of the level of pain. Staff documented will follow up with medications.)
02/05/2014, at 8:53 p.m. (The nursing "Assessment Report" dated 02/05/2014 revealed at 8:14 p.m., Patient #5 had pain at the back of her head. There was no assessment of the level of pain. Staff documented will follow up with medications.)
02/06/2014, at 8:56 a.m. and 11:36 p.m. (The nursing "Assessment Report" dated 02/06/2014 revealed at 7:15 a.m., Patient #5 complaint of pain at a level of 10).
02/08/2014, at 9:39 a.m. and 5:12 p.m. (No documentation of a pain assessment)
02/09/2014, at 4:33 a.m. and 2:17 p.m. (No documentation of a pain assessment)
02/10/2014, at 9:00 a.m. (No documentation of a pain assessment)
02/11/2014, at 7:28 a.m. (No documentation of a pain assessment)
02/12/2014, at 2:06 p.m., and 8:25 p.m. (The nursing "Assessment Report" dated 02/12/2014, revealed at 7:20 p.m., Patient #5 complained of pain at a level of 10 in the right extremity).
02/13/2014, at 10:50 a.m. (No documentation of a pain assessment)
There was no documentation of a thorough assessment of the location and level of before and after administration of pain medication.
Pain medication was not administered timely on 02/04, 02/05, 02/06 02/12 and 02/13/2014.

Review of nursing "Assessing Report" from 02/04-12/2014 revealed no documentation of consistent turning and repositioning every two hours on Patient #5.
During an interview on 02/13/2014 after 1:00 p.m., Staff #3 confirmed the missing assessments, delays in pain medication administration and problems with activities of daily living.


Review of a nursing "Assessment Report" revealed Patient #4 was an 80 year old male admitted on 02/11/2014, at 6:29 p.m. with a diagnosis of shortness of breath. At 11:41 p.m. there was documentation the patient was 54.4 kilograms (108.8 pounds) and was 5 feet 6 inches in height. He was independent in toileting, hygiene and eating.
A nursing assessment dated 02/13/2014, at 9:00 a.m. revealed Patient #4 was independent in transfers, eating, toileting and ambulation. Another assessment at the same time had him unsteady in gait, weak and needing assistance.
During an observation on 02/13/2014, at 9:59 a.m., Patient #4 was found with bilateral hands covered with dark purple ecchymotic areas. The left antecubital area had red and purple ecchymosis. Patient #4 was thin in frame and Staff #9 had to physically assist him from the bed to a bedside chair and provide him with a bath. Staff #9 reported Patient #4 could use the urinal alone, but she had to assist him to the bathroom for bowel movements.
Review of the clinical record and the nursing communication report revealed no documentation of an assessment of the condition of his arms.
Review of the activity of daily living flow sheet revealed no documentation of meal intakes in 2 of 5 opportunities for the timeframe from 02/12 -13/2014.
During an interview on 02/13/2014 after 1:00 p.m., Staff #3 confirmed the missing documentation.

Review of a nursing "Assessment Report" dated 02/12/2014, revealed Patient #10 was a 72 year old male who presented to the emergency room at 0023 a.m. The following was also documented:
On 02/12/2014, at 2:29 p.m. the emergency room documented they called report to Staff #10 (RN).
At 3:30 a.m., Staff #10 (LVN) documented receiving the patient from the emergency room and the chief complaint was altered mental status. Staff #10 documented an assessment which included past surgical and medical history, health history, psychosocial/functional /education, vital signs and an incomplete altered skin integrity assessment.
At 4:26 a.m., (over an hour later) Staff #11(RN) documented an assessment on the patient. According to her assessment Patient #10 had skin breakdown and scored a 15 on the Braden Scale. Documentation revealed Patient #10 had "small round sores to the thigh area and abdominal area, approximately 1 centimeter round. Partial scabbing. Zero drainage or odor; also redness noted to the buttock area; pics taken with measurements upon admission."
Review of the pictures did not show round sores on the thigh, it showed one sore on the left thigh. There was no picture of the abdomen. The redness to the buttock was not measured.
Review of the skin assessment dated 02/13/2014, at 7:08 a.m., was the same as the one on 02/12/2014.
The assessment was incomplete.
During an interview on 02/13/2014, after 1:00 p.m., Staff #3 confirmed the assessment was incomplete.

Review of a nursing "Assessment Report" dated 01/01/2014, at 00:55 a.m., revealed Patient #8 was a 68 year old female admitted with a chief complaint of cough and pain in the left hip. The patient had pain in her back at a level of 3.
Review of the "Medication Administration Record" revealed the following:
*An order for Hydrocodone 7.5/325 milligrams .... 1 tablet (orally) every 8 hours prn pain for a pain scale (5-7)
Patient #8 received doses on 01/01/2014, at 8:27 a.m., 3:27 p.m, and 10:20 p.m;
01/02/2014, at 6:07 a.m., 11:44 a.m. and 5:41 p.m.;
01/03/2014, at 1:36 a.m., 8:43 a.m. and 5:17 p.m.

*An order for Ultram 50 mg, 1 tablet orally every 6 hours for mild to moderate pain from (1-7)
Patient #8 received doses on 01/01/2014, at 1:35 p.m. and 10:20 p.m.;
01/02/2014, at 6:07 a.m., 3:03 p.m. and 10:08 p.m;
01/03/2014, at 4:46 a.m. , 1:48 p.m. and 9:34 p.m;
01/04/2014, at 8:33 a.m.

Review of the "Medication Administration Record" revealed the pain medication was administered 18 times. Review of nursing "Assessment Report" revealed only 4 assessments of pain documented.
During an interview on 02/13/2014, after 1:00 p.m., Staff #3 confirmed the missing pain assessments.

Review of the policy named "Pain Management" dated 09/2013, revealed the following:
I. ASSESSMENT OF PAIN:
All patients will be assessed for presence, absence and history of pain based on patient self-report (use behavioral indicators only when the patient is unable to self-report).
1) Initial data base on inpatients will include, but is not limited to the following factors:
a) description
b) intensity (using appropriate pain scale)
c) location
d) aggravating and alleviating factors
e) impact on functional ability
3) the pain intensity and pain relief as reported by the patient will be assessed and documented:
a) during initial nursing assessment, AND
b) after any known pain -producing event; AND
c) routinely at regular intervals (at least every shift); AND
d)more frequently according to the patient's needs/assessment; AND
e)after each pain management intervention, once a sufficient time period has elapsed for the treatment to reach peak effect.
III. INTERVENTION
B. Administer appropriate prescribed dose of pain medication based on the intensity of pain. (Mild, Moderate, or Severe)

Review of the policy named "Skin Integrity, Management of " dated 04/2013, revealed the following:
A skin assessment is conducted by the nurse on every patient upon admission to a unit, daily, and more frequently based on the risk assessment and patient's clinical status. ...
A risk assessment (Braden Scale) is completed by the nurse on every patient on first admission and will be repeated at least once daily. A risk assessment will also be conducted when there is a significant change in patient's condition, i.e. post surgery or sudden change in patient's condition. A patient is said to be at risk with a Braden Scale of 18 or less. If the Braden Score indicates the patient is At Risk, the nurse will initiate a full anatomic assessment using the "Altered Skin Integrity" chart.
Patients admitted with a pressure ulcer or found to have a hospital acquired pressure ulcer will have staging of the ulcer and wound characteristics documented by the nurses on admission to the unit and every 3 days thereafter and prior to discharge/transfer off unit. Follow NPUAP's definition of staging. A picture of the pressure ulcer should be taken appropriate patient identification and accurate location and description of the wound ...

Based on observation, interview and record review, the hospital failed to ensure nursing prepared thickened liquids as planned in 1 of 1 patients with swallowing difficulties (#5).
This deficient practice had the likelihood to cause harm in all patients that require thickened liquids.
Findings include:
Review of an admission "Assessment Report" dated 02/03/2014, 4:30 p.m., revealed Patient #5 was a 76 year old female who presented with chief complaints of shortness of breath.
Review of a nutritional assessment dated 02/05/2014, at 9:28 a.m., revealed the patient had a history of diabetes and was currently on a clear liquid diet. A recommendation was made by the dietitian that the patient would benefit from advancing from a clear liquid diet as soon as medically feasible.
Review of a nutritional assessment dated 02/11/2014, at 3:35 p.m., revealed Patient #5 had swallowing difficulty. The current diet order was Mechanical Soft, with honey thick liquids.

During an observation on 02/13/2014, at 10:15 a.m., Patient #5 was found with the following:
*In bed lying in a stool which was pooled underneath her. Her abdomen was distended, food particles were scattered all over the top bed covering and she was complaining of chest pain at a level of 10 (0 - nno pain and 10 - worst pain possible).
* Her lips were dry and the fluids at the bedside were not thickened. Two packets of thickener were on the bedside table and were not open.
Staff #3 gave Patient 5 sips of the unthickened water.
During an observation on 02/13/2014, at 10:47 a.m., (over 30 minutes later), Staff #6 administered pain medication to Patient #5. The patient stated she starts hurting everytime she drinks something.
Review of the nursing "Communication Report" for the day revealed Patient #5 was on Aspiration precautions and her liquids were to be thickened to honey consistency.
During an interview on 02/13/2014, after 11:00 a.m., Staff #3 revealed the "Communication Report" was used by nursing to document changes and keep up with what was going on with the patient. She confirmed the consistency of the water.

Based interview and record review, the facility failed to ensure pain medication was administered as ordered by the physician in 1 of 14 sampled patients (#8).
This deficient practice had the likelihood to cause harm in all patients that require pain medications.
Findings include:

Review of a nursing "Assessment Report" dated 01/01/2014, 00:55 a.m., revealed Patient #8 was a 68 year old female admitted with a chief complaint of cough and pain in the left hip. According to the assessment, Patient #5 had pain in her back at a level of 3 (0 - no pain and 10 - worst pain possible).
Review of the "Medication Administration Record" revealed the following:
*An order for Hydrocodone 7.5/325 milligrams .... 1 tablet (orally) every 8 hours prn pain for a pain scale (5-7)
Patient #8 received doses on 01/01/2014, at 8:27 a.m., 3:27 p.m, and 10:20 p.m.;
01/02/2014, at 6:07 a.m., 11:44 a.m. and 5:41 p.m.;
01/03/2014, at 1:36 a.m., 8:43 a.m. and 5:17 p.m.

*An order for Ultram 50 mg, 1 tablet orally every 6 hours for mild to moderate pain from (1-7)
Patient #8 received doses on 01/01/2014, at 1:35 p.m. and 10:20 p.m.;
01/02/2014, at 6:07 a.m., 3:03 p.m. and 10:08 p.m.;
01/03/2014, at 4:46 a.m. , 1:48 p.m. and 9:34 p.m.;
01/04/2014 at 8:33 a.m..

Review of nursing "Medication Administration Record" revealed the pain medication was administered 18 times.
Review of nursing the "Assessment Report" revealed only 4 assessments of the pain level documented.
The nurses failed to use the pain level scale as ordered for usage of the medication and the two doses of Hydrocodone was administered over 2 hours too soon on 01/02/2014.
During an interview on 02/13/2014, after 1:00 p.m., Staff #3 confirmed the missing pain assessments.

Review of the policy named "Pain Management" dated 09/2013 revealed the following:
III. INTERVENTION
B. Administer appropriate prescribed dose of pain medication based on the intensity of pain. (Mild, Moderate, or Severe)