HospitalInspections.org

Based on document review, medical record (MR) and interview, in 1 of 10 MRs, a patient (Patient #1) sustained an injury when aspiration precautions were not followed as ordered.

Findings include:

-- Per review of the hospital's policy and procedure (P&P) titled "Aspiration Prevention and Bedside Swallow Screening Protocol," last reviewed 11/11, it directs nursing to follow Speech Pathology directions specific to the patient's needs.

-- Per review of Patient #1's MR, he was admitted to the hospital on 1/3/18 with pneumonia. Past medical history included stroke, mental retardation, difficulty swallowing and aspiration pneumonia. Patient #1 had no teeth. Staff A (Occupational Therapist) completed a swallowing evaluation on 1/4/18. He/she recommended Patient #1 have a mechanical soft diet (meats ground with broth or gravy, breads cut small and moistened) with supervision during meal times for pacing. On 1/5/18 physician ordered aspiration precautions (head of bed elevated, suction at bedside), mechanical soft diet and supervision and pacing during meal times. On 1/9/18 physician ordered a clear liquid diet with thickened liquids because of possible bowel obstruction. On 1/13/18 Patient #1 was placed back on mechanical soft diet with thickened liquids.

Patient #1's nursing care plan initiated on 1/3/18 indicated assist with meals.

Nursing flowsheet documentation through from admission through breakfast on 1/14/18 revealed Patient #1 had one assist with feeding during all meals.

Nursing documentation on 1/14/18 at 12:55 pm indicated Patient #1 was awake and eating. At 1:05 pm nursing documentation indicated Patient #1 was found slumped in his chair unresponsive. Cardiopulmonary Resuscitation (CPR) was initiated, however oxygenation efforts were ineffective due to a piece of sliced pear lodged behind Patient #1's epiglottis. The pear slice was removed and Patient #1 was successfully intubated. Patient #1 remained unresponsive with sluggish pupils and was transferred to another hospital for a higher level of care.

Nursing documentation for lunch on 1/14/18 did not show evidence that Patient #1 was supervised during his meal.

-- Per interview of Staff B (Registered Nurse - Team Leader) on 3/19/18 at 2:00 pm, he/she was at the nurses station monitoring videos when a housekeeper came to him/her and stated Patient #1 didn't look good. He/she went to his room and found him slouched in his chair; he was not breathing and did not have a pulse. A code blue was called and CPR was started. He/she stated there was no staff with Patient #1 while he was eating lunch.

-- Per interview of Staff A on 3/20/18 at 11:30 am, during Patient #1's swallowing evaluation, the thing that struck him/her the most about him was that he was a fast eater. He/she documented the results of the swallowing evaluation in the MR and also had a conversation with the physician and registered nurse- team leader the day of his/her evaluation, emphasizing the importance of meal time supervision.

-- During interview of Staff C (Registered Nurse) on 3/20/18 at 3:00 pm, he/she acknowledged the above findings.

Based on document review and interview, the hospital did not review its policies and procedures (P&P) at least annually. This lack of P&P review could lead to inconsistencies in patient care.

Findings include:

-- Per review of hospital's P&P titled "Policy and Procedure Development," last revised 8/12/10, it states, "All policies will be on a three-year review cycle."

-- During interview of Staff D (Director of Quality Resources and Risk Management) on 3/19/18 at 1:40 pm, he/she acknowledged that P&P are not reviewed annually.

Based on document review, medical record (MR) review and interview, care provided to patients did not meet generally accepted standards of nursing practice or hospital policy and procedure (P&P). Specifically, 1) in 3 of 3 MRs (Patient #2, #3, and #4) reviewed, of patients at risk for pressure ulcer development, nursing staff did not consistently document turning and positioning of the patients, 2) in 1 of 4 MRs (Patient #2) reviewed, of patients with intravenous (IV) access, nursing staff did not document the IV insertion or ongoing assessment of the IV site, and 3) in 1 of 10 MRs (Patient # 4) reviewed, nursing staff did not implement a physician order after the order had been acknowledged. These lapses could lead to inadequate nursing care of patients.

Findings regarding 1) above include:

-- Review of the hospital's P&P titled "Pressure Ulcer Prevention and Management," dated 7/14/11, indicated when a patient is admitted to the hospital, the patient is assessed for risk of pressure ulcer formation while hospitalized using the Braden Scale for Predicting Pressure Ulcer Risk. The "Protocol for Prevention of Pressure Ulcers" is implemented whenever a patient's Braden score is less than 18. The protocol directs nursing staff on the procedures to follow and actions to take based on the results of the assessment. The protocol indicates, if a patient has a Braden score less than 15, the patient should be repositioned every 2 hours using a written schedule. Documentation should be done on unit specific flow sheets.

-- Per review of Patient #2's MR, she was a 93 year old female admitted on 3/18/18 with a diagnosis of inability to ambulate and an infection. On 3/18/18 and 3/19/18 her Braden score was documented as 13 (moderate risk for pressure ulcer development). She was bedfast and immobile. Nursing documentation from 3/18/18 at 7:56 pm to 3/19/18 at 2:38 am (6.5 hours) indicated Patient #2 was supine with head of bed (HOB) elevated 30 degrees. The next change of position was documented on 3/19/18 at 8:26 pm (18 hours later) indicating weight shift assistance given.

-- Per review of Patient #3's MR, she was a 93-year-old female admitted on 3/13/18 at 10:40 pm with a diagnosis of an infection and decreased appetite. Her Braden score on admission was 11 (high risk for pressure ulcer development). She was bedfast and had limited mobility. Additionally, Patient #3 had a pressure ulcer on her right buttocks on admission. Nursing documented on 3/13/18 at 11:22 pm, Patient #3 was lying on her left side, the next documentation of turning and positioning was 3/14/18 at 5:50 am (6 hours later) indicating Patient #3 was positioned on her right side and again at 11:00 pm (17 hours later) indicating Patient #3 was on left side.

-- Per review of Patient #4's MR, she was a 96-year-old female admitted on 3/18/18 with pneumonia. On 3/19/18 at 8:15 pm her Braden score was documented as 14 (moderate risk for pressure ulcer development). She was chairfast and had very limited mobility. Nursing documented Patient #4 was supine with the HOB elevated 30 degrees. The next documented position change was on 3/20/18 at 7:30 am (11 hours later) indicating she was supine, weight shift assisted, HOB elevated.

-- During interview of Staff E (Learning and Development Manager) on 3/20/18 at 1:30 pm, he/she acknowledged that the above patients were not turned and positioned every two hours.

Findings regarding 2) above include:

-- Review of the facility's P&P titled "Intravenous Peripheral Access Standards," last revised 7/2015, indicated nursing staff should document the insertion, maintenance, and removal of all vascular access devices. Catheter insertion sites should be inspected and palpated for tenderness every shift and information documented should include description of site, any complications or patient complaints.

-- Per review of Patient #2's MR, on 3/18/18 at 3:59 pm the provider ordered a peripheral IV. The order was acknowledged by nursing at 4:24 pm. There is no documentation in the MR of the IV insertion or site location. Patient #2 received an IV antibiotic on 3/18/18 at 11:53 pm and 3/19/18 at 11:00 pm, the MR lacked documentation by nursing staff regarding the IV site (e.g., location, appearance or patency).

-- During interview of Staff E (Learning and Development Manager) on 3/20/18 at 1:30 pm, he/she acknowledged the above findings.

Findings regarding 3) above include:

-- Per review of Patient # 4's MR, she was admitted to the hospital on 3/18/18 with a diagnosis of pneumonia. Patient #4 had been in a rehabilitation facility since the surgical repair of a left hip fracture on 2/16/18. She had completed a 21-day course of Lovenox (medication used to help reduce the risk of deep vein thrombosis [blood clot]), which may lead to pulmonary embolism (blood clot in the lung). Patient #4's D-Dimer (a lab test result which indicates possible blood clots) on admission was 5,558 (normal range 215-499) and she was given the differential diagnosis of pulmonary embolism. Lovenox was restarted for deep vein thrombosis prophylaxis. The physician wrote an order on 3/19/18 at 4:30 pm to apply sequential compression devices (therapy that helps prevent blood clots and pulmonary embolism in patients at risk). The order was acknowledged by nursing staff on 3/19/18 at 5:52 pm. There was no documentation in the MR regarding the application of the devices.

-- During interview of Staff E on 3/20/18 at 12:30 pm, he/she acknowledged the above findings.

Based on document review and interview, after an adverse patient event, the hospital did not fully implement risk reduction strategies. This could lead to another untoward event.

Findings include:

-- Per review of a hospital's root cause analysis (RCA), an inpatient was found unresponsive in his chair in his room during an unsupervised meal. He had no pulse or respirations. Cardiopulmonary Resuscitation (CPR) was started. A physician attempted to intubate the patient but was unable. On the second intubation attempt, a full slice of pear was removed from the patient's throat. (The patient was on aspiration precautions, required supervision with eating and the pears should have been cut into small pieces.) The patient was resuscitated but sustained a severe anoxic brain injury and subsequently died. Factors were identified that contributed to this event. Risk reduction strategies were implemented. The effectiveness of these new strategies was being measured. The hospital however, did not develop a policy and procedure (P&P) for a new meal tray checking process and lacked documentation of staff education of the new process.

-- Per interview of Staff D (Director of Quality Resources and Risk Management) on 3/20/18 at 3:15 pm, he/she acknowledged these findings.