HospitalInspections.org

Based on review of facility policy, medical records and interview with facility staff, it was determined the facility failed to obtain physician orders for the use of restraints for non-violent behavior. This affected 1 of 1 medical record reviewed including Patient Identifier (PI) # 8 and had the potential to negatively affect all patients who require restraints.

Findings include:

Facility Policy

Restraint Guidelines for Non-violent or Non-self-destructive Patients

Purpose: To provide information and guidelines on the use of physical restraints for non-violent or non-self-destructive reasons and insures the patient's rights, dignity, and wellbeing.

Guideline:

... Patients (not including patients needing restraints for violent or self-destructive reasons) are restrained for (a) prevention of medical device displacement or (b) impaired cognitive function, which interferes with medical treatment...

A physician's order is obtained immediately following the initiation of restraints and the physician examines the patient within 24 hours. Registered nurse assesses the patient and initiates the restraint... A physician, primarily responsible for the patient's ongoing care orders the use of restraints... A telephone/written order for restraints are to be times, dated and signed within 24 hours of receipt...

Procedure:
... 24. To continue restraints, obtain a physician order for renewal for restraints daily...

1. PI # 8 was admitted to the facility on 9/16/16 with acute respiratory failure and was placed on a ventilator and placed in soft wrist restraints. PI # 8 remained in restraints until 9/19/16 at 8:00 PM.

Review of the medical record revealed no documentation of a physician order for the continued use of soft wrist restraints for 9/18/16.

An interview was conducted on 9/29/16 at 10:55 AM with Employee Identifier # 2, Registered Nurse, who verified the above findings.

Based on review of medical record, facility policy, observation and interviews, it was determined the facility failed to ensure:

1. Nursing staff provided care according to physician's orders, including wound care, assisting patients out of bed to chair, suprapubic Catheter (Cath) and Foley Cath care, ambulation of the patient with assistance and turning the patient.

2. Nursing staff notified the physician and/or requested a wound care nurse consultation.

3. Wound care consultation was provided according to the physician's order.

This affected 5 of 5 records of patients with wounds, including Patient Identifier (PI) # 6, # 10, 8, 7, 9 and had the potential to negatively affect all patients served by the facility.

Findings include:

Facility Policy

Title: Skin Care - Wounds/Pressure Ulcers

Guideline:
On admission, per shift, and more often as needed, each patient's skin is assessed. The Braden Scale is used to identify skin risk... At risk patients, who score 17 or below on the Braden Scale, are put on the Pressure Ulcer Prevention Guidelines...

For patients with identified wounds, the staff needs to call the physician to initiate an order for the wound care nurses to see the patient. The wound care nurses implement an appropriate skin care protocol...

1. PI # 6 was admitted to the facility on 7/18/16 with the diagnosis including Status Post surgery (Urologic Surgery) Transurethral resection of the prostate (TURP).

Review of the 7/18/16 Skilled Nurse (SN) Admission Assessment note revealed documentation of the patient's skin assessment "within normal limits (WNL), skin warm, dry and intact, color pink, no edema or rash." Further review of the admission assessment revealed the patient's Plan of Care (POC) note. The POC revealed "problem - altered skin integrity, surgery Incision / procedure site: initiate."

Review of Physician's Order # 38 dated 7/18/16 revealed documentation to get the patient out of bed to chair Three times a day (TID) at 9 am -1 pm - 5 pm. There was no documentation the patient was assisted out of the bed to the chair except on 7/21/16. Review of the SN notes dated from 7/18/16 through 7/29/16 revealed no documentation the patient's refused to follow the physician's order.

Review of Physician's Order # 40 dated 7/18/16 revealed documentation for the SN to irrigate the Foley Cath with normal saline (NS) to 3-way each shift. Review of the SN notes dated from 7/18/16 through 7/29/16 revealed there was no documentation of irrigations performed each shift.

Review of Physician's Order # 158 dated 7/20/16 revealed documentation for the patient to ambulate with assistance every (Q) 3 hours. There was no documentation the patient was ambulated Q 3 hrs. Further review revealed no documentation the patient refused to follow the physician's order to ambulate.

Review of Physician's Order # 208 dated 7/25/16 revealed documentation for a wound management consult because the patient's "sacrum / crack raw from BMs (bowel movements)..." There was no documentation the wound nurse assessed the patient until 7/28/16, which was 3 days after the initiation of the physician's order for wound management consultation.

Review of Physician's Order # 222 dated 7/25/16 revealed documentation for the SN to keep a record of residual urine and plug suprapubic (SP) cath in the daytime.

Review of Physician's Order # 223 dated 7/25/16 revealed documentation for the SN to connect SP cath to gravity at night.

Review of the SN notes dated 7/25/16 through 7/27/16 revealed documentation of the SP cath was patent during day shift. Review of the SN note dated 7/28/16 revealed the first documentation he SP cath was clamped during day shift. Further review of the SN notes revealed no documentation residual urine was checked.

Review of Physician's Order # 304 dated 7/28/16 revealed orders for the SN to "clean wound with perineal cleanser; pat dry." Review of the SN notes dated from 7/28/16 and 7/29/16 revealed no documentation the patient's wound was cleaned with perineal cleanser and patted dry.

Review of Physician's Order # 305 dated 7/28/16 revealed documentation to provide pressure relief measures. There were no pressure relief measures documented.

An interview was conducted on 9/29/16 at 12:37 PM with Employee Identifier (EI) # 4, Interim Unit Director / Charge Nurse, who verified the above findings.

2. PI # 10 was admitted to the facility on 9/20/16 with the diagnoses including Dehydration and Constipation.

Review of the Emergency Department SN note dated 9/20/16 revealed documentation of a pressure ulcer to Left Gluteal stage 1. Review of the medical record revealed no documentation of the wound during the patient's hospitalization from 9/20/16 to 9/29/16.

Review of Physician's Order # 293 dated 9/26/16 revealed documentation to get the patient out of bed to chair Two times a day (BID) at 6 am - 6 pm. There was no documentation the patient was assisted out of the bed to the chair. Review of the SN notes dated from 9/26/16 through 9/28/16 revealed no documentation the patient refused to follow the physician's order.

Review of Physician's Order # 218 dated 9/21/16 revealed documentation to turn patient Q 2 hours. There was no documentation the patient was turned every 2 hours except on 9/28/16.

An interview was conducted on 9/29/16 at 2:36 PM with Employee EI # 3, Unit Director, who verified the above findings.



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3. PI # 8 was admitted to the facility on 9/16/16 with acute respiratory failure, was intubated and transferred to the cardiac care unit.

Review of the Clinical Notes/Comments dated 9/17/16 at 4:15 AM revealed, "... This is a notice to enter a nursing trigger consult order... and "...Please provide a wound consult due to a Braden Scale of 12..."

Review of the Admission Assessment dated 9/17/16 at 4:33 AM, the Registered Nurse (RN) documented the patient's Braden Scale score was 12. The RN documented the patient's skin color was pale, ecchymotic, intact, cool, dry and fragile.

Review of the nursing Plan of Care dated 9/17/16 at 11:30 PM revealed the patient had a problem with skin integrity with goals of absence of signs and symptoms of infections and decrease in wound size.

Review of the RN pressure ulcer assessment dated 9/17/16 at 11:30 PM revealed the nurse documented the patient had a suspected deep tissue injury to the left heel and applied waffle boots to float heels.

There was no documentation the nurse notified the physician and/or requested a wound care nurse consultation.

Review of the RN pressure ulcer assessments dated 9/18/16 at 8:00 AM, 9/18/16 at 7:30 PM and 7:45 PM revealed the RNs continued to document the patient had a suspected deep tissue injury to the left heel.

There was no documentation the RN completed assessments of the left heel pressure area until 9/21/16 at 7:05 AM at which time, the RN documented having noted a blistered area to the left heel and a stage 1 pressure area to the sacrum.

There was no documentation the nurse notified the physician and/or requested a wound care nurse consultation.

Review of the RN pressure ulcer assessment dated 9/21/16 at 7:00 PM revealed the RN documented the patient continued to have a suspected deep tissue injury to the left heel and a stage 1 pressure area to the sacrum.

Review of the Physician's order dated 9/21/16 at 9:00 PM revealed a verbal order for a wound consult for left heel and sacrum.

Review of the Wound Comprehensive assessment dated 9/22/16 at 9:50 AM revealed the patient had an area of redness to the left heel with no open areas that appeared to be healed / healing stage 2 pressure injury and redness to the peri-rectal area from IAD (incontinent associated dermatitis).

The wound care consult was conducted 5 days after the RN assessed the patient's Braden scale of 12 (9/17/16 admission to the intensive care unit) and it was identified that a wound care consult was warranted.

An interview was conducted on 9/29/16 at 10:55 AM with EI # 2, RN, who stated the "trigger for wound care consultation" was a prompt and not a physician's order for wound care consultation. EI # 2 stated that the initial order for the wound care nurse consult was on 9/21/16 at 9:00 PM.

4. PI # 7 was admitted to the facility on 9/24/16 with right plantar surface toe ulcer.

Review of the History and Physical dated 9/24/16 revealed the patient complained of redness, swelling, pain and an ulcer to the plantar surface of the right toe for one month. The physical examination revealed the patient had an ulceration to the right plantar portion of the toe which measured 2 centimeters (cm) by 2 cm, which was oozing necrotic tissue.

The assessment and plan included: "... 6. Sacral ulcer has been previously worked up in the past according to the patient it is getting better. Will get Wound Care on board to help us..."

Review of the electronic medical record physician's order dated 9/24/16 at 11:47 PM revealed orders for wound management consult with the following comments: "... Type 4 ulcer of R plantar (toe)..." This order was signed by the physician at 11:49 PM and reviewed and signed by the RN on 9/25/16 at 3:00 AM.

Review of the Physician's order dated 9/25/16 at 9:09 AM revealed, "... Please ensure dietician consult, wound care consult... in place, if not order.."

Review of the electronic medical record physician's orders dated 9/25/16 at 9:33 AM, revealed the RN entered the above physician order for wound management consult with the following comments, "... wound care 9/25/16..."

Review of the Wound Comprehensive Assessment dated 9/26/16 at 9:50 AM revealed the wound care nurse documented an assessment of the pressure wound to the coccyx, which extended to the gluteal cleft. Plan of care for this wound was to use barrier ointment to promote healing and protect along with pressure redistribution measures. The wound care nurse further documented, "... Pt (patient) has right plantar wound, will defer to vascular who has been consulted for this wound..."

Review of the Physician's Progress Note dated 9/27/16, which was signed by the physician at 3:22 PM revealed the physician documented, "... Diabetic foot ulcer... wound care to see if (he/she) needs debridement..."

Review of the Wound Comprehensive Assessment dated 9/27/16 (Tuesday)at 4:27 PM revealed the nurse documented, "... Pt with wound to right plantar 1st metatarsal head. Pt states... goes to the wound clinic in Athens. Noted necrotic tissue/callous that is dry surrounding wound - per pt they will "cut that off" at (his/her) next appointment. Wound bed is moist with slough and red flat tissue. Instructed pt to continue Santyl at home per wound clinic instructions. Pt/daughter verbalized instructions. Pt has appointment with wound clinic this Friday... (3 days later)"

The wound care nurse's assessment was 3 days after the initial physician's order dated 9/24/16 for wound care consultation. The patient's skin was discharged from the facility on 9/27/16.

An interview was conducted on 9/29/16 at 1:12 PM with EI # 3, Unit Director who verified the above findings. EI # 3 stated he did not know why the wound care consult for the right foot wound was not completed until 9/27/16. He stated wound care assessments were usually completed within 24 hours after a physician order has been entered.

5. PI # 9 was admitted to the facility on 9/19/16 with status post coronary artery bypass graft now with pulmonary edema and was admitted to the intensive care unit (ICU).

Review of the physician's order dated 9/19/16 at 9:36 PM revealed, "... Nursing... routine incision care..." There was no documentation in the medical record what "routine incision care" orders included. There were no specific wound care orders including cleaning solutions to be utilized, type dressing, if any to be applied or a location of the incision site. There was no documentation the nurse clarified the physician order as written for "routine incision care".

Review of the ICU Initial Nursing Assessment dated 9/20/16 at 7:13 AM revealed the nurse documented the patient's skin was intact. Review of the ICU Assessment dated 9/25/16 at 9:25 AM revealed the nurse documented the patient was intact.

The patient was transferred to the nursing unit on 9/25/16.

Review of the Wound Assessment portion of the electronic medical record (EMR) revealed on 9/26/16 at 7:00 PM, the nurse documented the patient had a stage 3 pressure ulcer to the sacral area with black/yellow/red tissue and serosanguinous drainage and the Certified Registered Nurse Practitioner was notified.

Review of the Adult Shift Assessment dated 9/26/16 at 11:28 PM revealed the nurse documented the patient had a stage 3 pressure ulcer to the sacral area with black/yellow/red tissue and serosanguinous drainage.

Review of the Wound Assessment portion of the EMR revealed documented on 9/27/16 at 3:00 AM, the nurse documented the patient continued to have a stage 3 pressure ulcer to the sacral area with yellow/red tissue and serosanguinous drainage.

Review of the Wound Assessment portion of the EMR revealed no documentation the nurse assessed the stage 3 pressure ulcer to the sacral area on 9/27/16 at 7:00 AM, 1:20 PM and 6:00 PM.

Review of the Wound Assessment portion of the EMR revealed documented on 9/27/16 at 7:00 PM and 11:00 PM the nurse documented the patient continued to have the stage 3 pressure ulcer to the sacral area with yellow/red tissue and serosanguinous drainage.

On 9/29/16 at 2:36 PM, the surveyor observed the patient's sacral area in the presence of EI # 1, Chief Nursing Officer and EI # 5, Certified Registered Nurse Practitioner (CRNP)/Educator. During this observation, the surveyor observed the patient had a possible stage 3 pressure ulcer to the sacral area, which was approximately 1.25 centimeters (cm) by 1.25 cm. The surveyor was unable to determine the depth of this pressure ulcer due to slough/grayish tissue covering the wound bed.

An interview was conducted on 9/29/16 at 2:36 PM with EI # 6, CRNP on the unit where the patient was located. EI # 6 stated there was a wound care team consult for this patient. She stated the note had not been completed in the EMR.

Review of the Wound Comprehensive Assessment dated 9/29/16 at 4:20 PM revealed the wound care nurse documented, "... Wound note: coccyx. Pt has unstagable pressure injury noted on ... coccyx... Plan of care: calmoseptine to promote healing and protect. Will continue with pressure redistribution... Will follow progress..."

An interview was conducted on 9/29/16 at 2:50 PM with EI # 5 and EI # 7, Unit Director who stated the nurse should have consulted the CRNP then should have put in an order for wound care consult at the time she identified the pressure area to the sacral area.

Based on review of medical records and interviews with facility staff, it was determined the nursing staff failed to follow the nursing plan of care for 1 of 5 patient records reviewed with wounds. This affected Patient Identifier (PI) # 8 and had the potential to negatively affect all patients admitted to this facility.

Findings include:

1. PI # 7 was admitted to the facility on 9/24/16 with right plantar surface toe ulcer.

Review of the History and Physical dated 9/24/16 revealed the patient complained of redness, swelling, pain and an ulcer to the plantar surface of the right toe for one month. The physical examination revealed the patient had an ulceration to the right plantar portion of the toe which measured 2 centimeters (cm) by 2 cm, which was oozing necrotic tissue.

The assessment and plan included: "... 6. Sacral ulcer has been previously worked up in the past according to the patient it is getting better. Will get Wound Care on board to help us..."

Review of the nursing Plan of Care dated 9/24/16 at 11:01 PM revealed interventions for altered skin integrity included assessment of skin integrity every 4 hours.

Review of the nursing Admission Assessment dated 9/25/16 at 12:39 AM revealed the patient had altered skin integrity with a diabetic wound to the right foot and a stage 3 pressure ulcer to the sacral area.

Review of the nursing documentation revealed no documentation of an assessment of the skin every 4 hours. The nursing documentation for altered skin integrity was completed on 9/25/16 at 7:30 AM and 7:30 PM.

The nursing documentation for altered skin integrity was completed on 9/26/16 at 1:00 PM and 6:56 PM. There was no documentation of an assessment of the right plantar surface of the toe completed at 1:00 PM.

There was no documentation the nursing staff assessed the patient's altered skin integrity every 4 hours according to the nursing plan of care.

An interview was conducted on 9/29/16 at 1:12 PM with Employee Identifier # 3, Unit Director, who verified the above findings.