HospitalInspections.org

Based on record reviews and interviews, the hospital failed to ensure care in a safe setting. This deficient practice was evidenced by a patient obtaining skin injuries of unknown origin while admitted for 1 (#2) of 3 (#1, #2, #3) patients reviewed.

Findings:

Review of Patient #2's medical record revealed an admission date of 06/26/2024 and a discharge date of 07/08/2024. Review of the admission nursing assessment dated 06/26/2024 11:30 p.m. revealed in part:
Integumentary (Integumentary Assessment within defined parameters = intact, color appropriate to ethnicity, warm and dry to touch.) - Within Define Parameters
Sensory (ability to respond meaningfully to pressure-related discomfort) - Slightly Limited
Moisture (Degree to which skin is exposed to moisture) - Rarely Moist
Activity - Walks Occasionally
Nutrition (Usual foot intake pattern) - Adequate
Friction and Shear - Potential Problem
Score Total of Skin Risk - 12.0
Level of Risk Indicated by Score - Score Total 10 to 12 = Level 3 (High Risk)
Is there an indication of a pressure ulcer or other skin breakdown present on admission? - Yes

Review of the Weekly Skin Assessment dated 06/27/2024 11:43 p.m. revealed in part, New Findings
1 - Location of Site - Back of Left Arm - Elbow
Comment: skin tear
Color of Wound- Red
Color of Drainage at Site - None
Dressing - Other Comment: tegaderm
Type of Finding - Skin Tear
Color of the skin around the wound - Red
2 - Location of Site - Back of Left Arm - Back of Upper Arm
Color of Wound - Red
Color of Drainage at Site - None
Dressing - Other Comment: tegaderm
Type of Finding - Skin Tear
Color of skin around the wound - Red

Review of the Weekly Skin Assessment dated 06/29/2024 9:14 a.m. revealed in part, No New Findings
1 - Location of Site - Back of Left Arm - Elbow
Comment: skin tear
Color of Wound- Red
Color of Drainage at Site - None
Dressing - Other Comment: tegaderm
Type of Finding - Skin Tear
Color of the skin around the wound - Red
2 - Location of Site - Back of Left Arm - Back of Upper Arm
Color of Wound - Red
Color of Drainage at Site - None
Dressing - Other Comment: tegaderm
Type of Finding - Skin Tear
Color of skin around the wound - Red
3 - Location of Site - Front of Right Leg - Front of Lower Leg
Type of Finding: Bruise
Color of Wound - Bruised
Color of the skin around the wound - Bruised
Odor from Site - None
Dressing - Dry and Intact

Review of the Weekly Skin Assessment dated 07/06/2024 1:16 p.m. revealed in part, Wound to back of left hand and multiple scabs on lower and upper extremities with bruises.
1 - Location of Site - Back of Left Arm - Elbow
Comment: skin tear
Color of Wound- Red
Color of Drainage at Site - None
Dressing - Other Comment: tegaderm
Type of Finding - Skin Tear
Color of the skin around the wound - Red
2 - Location of Site - Back of Left Arm - Back of Upper Arm
Color of Wound - Red
Color of Drainage at Site - None
Dressing - Other Comment: tegaderm
Type of Finding - Skin Tear
Color of skin around the wound - Red
3 - Location of Site - Front of Right Leg - Front of Lower Leg
Type of Finding: Bruise
Color of Wound - Bruised
Color of the skin around the wound - Bruised
Odor from Site - None
Dressing - Dry and Intact
4 - Location of Site - Back of Left Hand - Back of Hand
Type of Finding - Open Wound
Color of Wound - Yellow
Color of the skin around the wound - Pink
Color of Drainage at Site - None
Odor from Site - None
Dressing - Dry and Intact
5 - Location of Site - Front of Left Leg - Front of Lower Leg
Type of Finding - Skin Tear Comment: multiple skin tears
Color of Wound - Black
Color of skin around the wound - Pink
Color of Drainage at Site - None
Odor from Site - None
Dressing - None Applied
6 - Location of Site - Back of Right Arm - Back of Lower Arm
Type of Finding - Scab Comment: multiple scabs to back of lower arm
Color of Wound - Black
Color of the skin around the wound - Pink
Color of Drainage at Site - None
Odor from Site - None
Dressing - None Applied
7 - Location of Site - On Back - Spine Comment: redness to both sides of back
Type of Finding - Other Comment: Redness
Color of Wound - Red
Color of skin around the wound - Pink
Color Drainage at Site - None
Odor from Site - None
Dressing - None Applied
8 - Location of Site - Back of Left Arm - Back of Lower Arm
Color of Wound - Black
Color of Drainage at Site - None
Dressing - Dry and Intact
Odor from Site - None
Type of Finding - Scab Comment: multiple scabs
Color of the skin around the wound - Pink

Review of the nursing note dated 07/02/2024 6:35 a.m. revealed in part, Patient #2 sitting in geri chair picking skin to bilateral upper extremities noted by MHT and LPN.

In a phone interview on 08/21/2024 at 2:16 p.m. S5LPN stated Patient #2 had a lot of bruising at admission. S5LPN stated Patient #2 did have a skin tear to the left arm. S5LPN stated Patient #2 had a skin tear to his left hand. S5LPN stated when they would draw blood Patient #2 would bruise easily. S5LPN stated she did not know how Patient #2 got the skin tears.

In an interview on 08/21/2024 at 2:51 p.m. S1CNO and S2DQ stated it appeared from the documentation and pictures that Patient #2 inquired these skin injuries during his psychiatric admission. S2DQ stated there was documentation that Patient #2 would "pick" himself. S2DQ stated the LPN from the psychiatric unit reported the scratches were self-inflicted by Patient #2. S2DQ stated S4DON reported she did a chart check and the areas of concern were not reported to the inpatient medical unit upon transfer but were documented on the skin assessment on 07/01/2024 and 07/06/2024.

In an interview on 08/21/2024 at 3:07 p.m. S6RN stated he did not know how Patient #2 got the skin tears or bruising. S6RN stated he was not at the hospital when it happened. S6RN stated he was off and when he came back, he found the wounds. S6RN stated Patient #2's hand was bandaged. S6RN stated S7LPN and S8NP were rounding together and removed the bandage from Patient #2's hand.

In an interview on 08/21/2024 at 3:17 p.m. S7LPN stated when she got off of shift on Thursday Patient #2 had the skin tears to upper arm. S7LPN stated Patient #2 did not have the bruising and skin tears to the hand. S7LPN stated when she returned to shift on Monday the bruising and skin tears were a new concern with Patient #2.

In a phone interview on 08/22/2024 at 10:19 a.m. S9LPN stated she remembered Patient #2 had bruises. S9LPN stated she did not know if anything happened to Patient #2's left hand. S9LPN stated if she remembered correctly Patient #2 had a tegaderm on the back of his hand. S9LPN stated it did not happen on her shift. S9LPN stated she did not know what happened to Patient #2's left hand. S9LPN stated Patient #2's skin was really thin. S9LPN stated she didn't know if Patient #2 got the skin tear from having thin skin. S9LPN stated she didn't know how Patient #2 got the skin tear.

In a phone interview on 08/22/2024 at 1:44 p.m. S10CNA stated she did not know where the skin tears or skin issues came from. S10CNA stated she remembered when she left Patient #2 had nothing. S10CNA stated when she came back Patient #2's hand was wrapped. S10CNA stated she didn't quite remember how many days in between but does remember nothing was wrong when she took care of Patient #2 and then when she returned to work Patient #2's hand was wrapped. S10CNA stated she didn't remember Patient #2 having any skin tears to his legs. S10CNA stated maybe he moved around and maybe bumped his arm on a chair or something. S10CNA stated when people have fragile skin it could have happened that way. S10CNA stated she wasn't certain how Patient #2 got the skin tears to his arm.

In an interview on 08/22/2024 at 3:47 p.m. S1CNO stated drawing blood could have caused the bruising to Patient #2's hand. S1CNO stated Patient #2's skin was very thin. S1CNO stated she could not determine for certain what caused the skin injuries to Patient #2's hand.

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation (CoP) for Nursing Services. The deficient practice was evidenced by:

1) Failure of the nursing staff to perform or assist in activities of daily living (ADLs) as per hospital policy for 2 of 2 (#2, #3) patients reviewed for ADLs from a total sample of 3 and failure of the RN to review and validate an initial admission assessment conducted by a LPN for 1 (#1) of 3 (#1, #2, #3) patients reviewed (see Findings in A-0395).

2) Failing to update a care plan after a fall for 1 (#1) of 3 (#1, #2, #3) patients reviewed and failing to create individualized care plans based on assessments for 1 (#2) of 3 (#1, #2, #3) patients reviewed (see Findings in A-0396).

Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:

1.) failure of the nursing staff to perform or assist in activities of daily living (ADLs) as per hospital policy for 2 of 2 (#2, #3) patients reviewed for ADLs from a total sample of 3; and

2.) failure of the RN to review and validate an initial admission assessment conducted by a LPN for 1 (#1) of 3 (#1, #2, #3) patients reviewed.


Findings:

1.) Failure of the nursing staff to perform or assist in activities of daily living (ADLs) as per hospital policy for 2 of 2 (#2, #3) patients reviewed for ADLs from a total sample of 3.

Review of the hospital's policy titled "Personal Hygiene" effective date 09/21/2021, revealed in part, all patients shall be encouraged or assisted in grooming daily or more often as needed. Grooming articles such as bath soap dispenser, shampoo, body powder, shaving equipment, etc., are available per patient need. Shower or sponge bath to be provided with staff supervision and/or assistance.

Patient #2
Review of Patient #2's medical record revealed an admission date of 06/26/2024. Review of the skin assessment photographs revealed Patient #2 wearing the same clothes on 06/26/2024, 06/27/2024, and 06/29/2024. Review of the daily skin audit and bath sheets presented by S4DON and S3ADQ revealed the following:
06/26/2024- No bath given / Other: scabbed area
06/27/2024- No bath given
06/27/2024- Bath given / bed bath
06/28/2024- No bath given
06/29/2024- No bath given
06/30/2024- No bath given
07/01/2024- Bath given
07/01/2024- No bath given
07/02/2024- No bath given
07/02/2024- No bath given; date of last bath: 07/01/2024 / no findings
07/03/2024- No bath given
07/04/2024- Bath given / no findings
07/04/2024- No bath given
07/05/2024- No bath given
07/05/2024- No bath given
07/06/2024- Bath given / sponge bath / no findings
No documentation for 07/07/2024

Review of the daily skin audit and bath sheets there was no documentation of Patient #2 having a bath on the following dates: 06/28/2024; 06/29/2024; 7/2/2024; 7/3/2024; 7/5/2024; and 7/7/2024.

In an interview on 08/22/2024 at 9:52 a.m. S1CNO verified the expectation is daily bath/shower for patients.

In an interview on 08/22/2024 at 9:55 a.m. while reviewing the skin assessment photographs, S2DQ verified Patient #2 was wearing the same clothes on 06/26/2024, 06/27/2024, and 06/29/2024.

In an interview on 08/22/2024 at 12:25 p.m. S1CNO verified there was no documentation of Patient #2 having a bath on the above stated dates.

Patient #3
Review of Patient #3's medical record revealed an admission date of 08/10/2024. Review of the ADL documentation that was included in Patient #3's medical record revealed on 08/10/2024 10:34 p.m. assisted with bath; 08/14/2024 10:43 p.m. bathed self; and 08/21/2024 12:02 a.m. complete (total) bath performed, hair shampoo, bathed self. There was no documentation of Patient #3 having a bath on the following dates: 08/11/2024; 08/12/2024; 08/13/2024; 08/15/2024; 08/16/2024; 08/17/2024; 08/18/2024; 08/19/2024; and 08/20/2024.

In an interview on 08/22/2024 at 3:15 p.m. S1CNO verified there was no documentation of Patient #3 having a bath on the above stated dates.

2.) Failure of the RN to review and validate an initial admission assessment conducted by a LPN for 1 (#1) of 3 (#1, #2, #3) patients reviewed.

Review of the hospital's policy titled "Admission/Assessment" effective date 09/21/2021, revealed in part, at the time of admission each patient shall have an initial physical and psychological assessment completed by a registered nurse (RN). A licensed practical/vocational nurse (LPN or LVN) may conduct basic elements of the assessment under the direct supervision of a RN, and report these on the nursing assessment and to the RN. The RN will sign-off on any assessments performed by the LPN or LVN under the RN's supervision.

Review of Patient #1's medical record revealed an admission date of 06/21/2024. Review of the initial admission assessment revealed the assessment was conducted on 06/21/2024 at 9:01 p.m. by S5LPN. Further review revealed no documentation of the assessment being reviewed and validated by a registered nurse.

In an interview on 08/20/2024 at 2:54 p.m. S4DON verified S5LPN is a licensed practical nurse. S4DON stated an RN should have reviewed, verified, and signed the initial admission assessment.

In an interview on 08/20/2024 at 2:56 p.m. S2DQ verified there was no documentation that a RN reviewed, verified, and signed Patient #1's initial admission assessment.

Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed, and kept a current, and individualized nursing care plan for each patient that reflected the patient's goals and the nursing care expected to meet the patient's needs. This deficient practice was evidenced by:

1.) failing to update a care plan after a fall for 1 (#1) of 3 (#1, #2, #3) patients reviewed; and

2.) failing to create individualized care plans based on assessments for 1 (#2) of 3 (#1, #2, #3) patients reviewed.

Findings:

1.) Failing to update a care plan after a fall for 1 (#1) of 3 (#1, #2, #3) patients reviewed.

Review of the hospital's policy titled "Master Treatment Plan, Treatment Team, Treatment Plan Updates" effective date 09/21/2021, revealed in part, the master treatment plan is continuously reviewed and updated for effectiveness. The plan is updated with findings and results from ongoing evaluations, assessments, and diagnostic testing. Each member of the interdisciplinary team contributes findings and updates in the treatment team process. The master treatment plan is kept current with these updates.

Review of Patient #1's medical record revealed an admission date of 06/21/2024 and a discharge date of 07/03/2024. Review of the nursing notes revealed in part, 07/03/2024 12:25 a.m.: 12:25 a.m.- notified by roommate that resident fell on buttocks coming from bathroom. Upon entering room resident was noted on floor near bed in sitting position. Complete head to toe assessment done. Bruise noted under right eye. Patient #1 was asked what happened "patient stated I don't know" assisted to bed x2 staff members. Neuro checks initiated. Notified house supervisor, physician and family. No c/o pain or discomfort. Intervention to prevent future falls, maintain adequate lighting. There was no documentation of the care plan being updated after Patient #1's fall and prior to Patient #1 being discharged the same day.

In an interview on 08/21/2024 at 10:15 a.m. S1CNO verified the care plan should have been updated after Patient #1's fall.

2.) Failing to create individualized care plans based on assessments for 1 (#2) of 3 (#1, #2, #3) patients reviewed.

Review of the hospital's policy titled "Master Treatment Plan, Treatment Team, Treatment Plan Updates" effective date 09/21/2021, revealed in part, C. Admitting Nurse/Charge Nurse: opens initial care plans for nursing services in the Master Treatment Plan, including the preliminary plans of care addressing psychiatric and non-psychiatric conditions, within eight (8) hours of admission. Opens the problem list of needs based on medical and psychiatric diagnoses and presenting symptomatology. Problem needs are listed and addressed in order of severity, beginning with psychiatric needs. Revises and develops the medical components of the master treatment plan based on ongoing assessment findings and physician's orders.

Review of Patient #2's medical record revealed an admission date of 06/26/2024. Review of the weekly skin assessment dated 06/27/2024 at 11:43 p.m. revealed skin tear to back of left arm elbow and skin tear to back of upper left arm. Review of the weekly skin assessment dated 06/29/2024 at 9:14 a.m. revealed skin tear to back of left arm elbow, skin tear to back of upper left arm, and bruise to front of lower right leg. Review of the weekly skin assessment dated 07/06/2024 at 1:16 p.m. revealed skin tear to back of left arm elbow, skin tear to back of upper left arm, bruise to front of lower right leg, open wound to back of left hand, multiple skin tears to front of lower left leg, multiple scabs to back of lower right arm, redness to both sides of back and multiple scabs to back of lower left arm. Review of the treatment plan failed to reveal a plan related to skin integrity.
Review of the progress note dated 07/08/2024 at 8:10 a.m. revealed in part, Medical F/U 07/03/2024- not eating or drinking much, 07/02/2024 IV fluid for hydration. Medical F/U today- Patient #2 with continued decline, likely aspirating with food. Patient with continued decline over the weekend - today not eating or drinking, on IV fluid for hydration. Review of the treatment plan failed to reveal a plan related to nutrition.

In an interview on 08/22/2024 at 4:15 p.m. S1CNO verified skin integrity and nutrition were not addressed in Patient #2's care plan. She stated skin integrity and nutrition should have been included in Patient #2's care plan.

Based on record reviews and interviews, the hospital failed to ensure all practitioner's orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, vital signs, and other information necessary to monitor the patient's condition were contained in patients' medical records. This deficient practice was evidenced by:

1.) failing to ensure an observation order for patients in a psychiatric unit was included in the medical record for 3 of 3 (#1, #2, #3) medical records reviewed;

2.) failing to ensure documentation of activities of daily living (ADLs) were included in the medical record for 1 (#2) of 2 (#2, #3) medical records reviewed for ADLs from a total sample of 3.

Findings:

1.) Failing to ensure an observation order for patients in a psychiatric unit was included in the medical record for 3 of 3 (#1, #2, #3) medical records reviewed.

Patient #1
Review of Patient #1's medical record revealed an admission date of 06/21/2024. Review of the physician orders failed to reveal an order for observation for patients in a psychiatric unit.

In an interview on 08/22/2024 at 4:00 p.m. S2DQ verified there was no documentation of an observation order in Patient #1's medical record.

Patient #2
Review of Patient #2's medical record revealed an admission date of 06/26/2024. Review of the physician orders failed to reveal an order for observation for patients in a psychiatric unit.

In an interview on 08/22/2024 at 10:13 a.m. S1CNO verified there was no documentation of an observation order in Patient #2's medical record. She stated observation order is included in the order set but was not selected for Patient #2.

Patient #3
Review of Patient #3's medical record revealed an admission date of 08/10/2024. Review of the physician orders failed to reveal an order for observation for patients in a psychiatric unit.

In an interview on 08/22/2024 at 2:20 p.m. S2DQ verified there was no documentation of an observation order included in Patient #3's medical record.

2.) Failing to ensure documentation of activities of daily living (ADLs) were included in the medical record for 1 (#2) of 2 (#2, #3) medical records reviewed for ADLs from a total sample of 3.

Review of Patient #2's medical record revealed an admission date of 06/26/2024. Further review revealed ADLs were not documented in Patient #2's medical record. The daily skin audit and bath sheets that were presented by S4DON and S3ADQ were kept on the unit.

In an interview on 08/22/2024 at 9:44 a.m. S2DQ verified there was no documentation of ADLs, shower/bath, etc. included in Patient #2's medical record.

In an interview on 08/22/2024 at 11:02 a.m. S1CNO verified the daily skin audit and bath sheets were not part of Patient #2's medical record. S1CNO stated ADLs should have been documented in Patient #2's medical record.