HospitalInspections.org

Based on the review of one of two medical records, Medical Record #2, facility document review, and staff interviews, it was determined that the facility failed to ensure that nursing care is provided in accordance with physicians' orders.

Findings include:

Review of Medical Record #2 (MR2) conducted on 6/1/23, in the presence of Staff #4 (S4), a registered nurse (RN) and Quality Assurance Specialist, identified a physician's order #588390795, dated 5/21/23 at 17:56 (5:56 PM), which stated, "... Body temperature check ... frequency every hour ... Comments: If temperature < [is less than] 97 degrees F [Fahrenheit], initiate warming blanket to maintain body temperature 97 to 100 degrees F."
The vital signs flow sheet found in MR2 dated 5/22/23 at 1200 (12:00 PM), 1300 (1:00 PM), and 1400 (2:00 PM) indicated that Patient #2's temperature was 96.2, 95.5, and 95.5 degrees Fahrenheit respectively.
The nursing assessment flow sheet found in MR2, dated 5/22/23 at 1200 (12:00 PM) and 14:00 (2:00 PM), indicated that heat was applied at those times, but does not identify the method used to apply heat.
The nursing assessment flow sheet found in MR2, dated 5/22/23 at 2000 (8:00 PM), indicated that the heat was removed, burn and blisters were noted.
The supplementary note entered into the medical record on 5/22/23 at 21:00 (9:00 PM). states, "...Called to bedside by RN for blistering burns assessed on B/L [bilateral] abd [abdomen] and groin appearing to be from hot packs. ... Silvadene cream ordered. Wound Consult placed. Sharing Network RN made aware."
The Wound Care Evaluation note dated 5/23/23 at 11:13 AM, states, "... Plan for patient to go to OR [operating room] for organ procurement unchanged, with estimated 1 PM OR. Assessment: 66 year old male with thermal skin injury, consistent with second degree burn, noted to bilateral abdomen, groin and suprapubic area ..."

During a facility tour of the Neuro ICU (Intensive Care Unit) and Surgical ICU on 6/1/23, nursing staff were interviewed about the methods utilized to treat hypothermia. In the Surgical ICU at 12:00 PM, S9, a RN, stated that the usual methods used to increase body temperature are either warm blankets or a Bair hugger. S9 stated that if these were not immediately available in the unit, he/she would contact another unit or central supply to obtain them.

At 12:05 PM in the Neuro ICU, S5, a RN, stated that the physician's order would specify the method used to increase low body temperature. S5 stated that the methods he/she has used in the facility were either warm blankets or a Bair hugger. S5 indicated that both were currently available in the Neuro ICU.

At 12:10 PM in the Neuro ICU, S6, RN, and S14, an ICU RN orientee, stated that if a patient was hypothermic, treatment would usually start with warm blankets and then a Bair hugger would be used. They stated that management of the hypothermia would be based on the provider's orders. S6 stated that he/she had more than six years of experience working in the ICU setting and had only ever used warm blankets or a Bair hugger to increase body temperature.

On 6/1/23, the facility's incident reporting documentation for the patient burn identified on 5/22/23, was requested and reviewed. The incident report was filed on 5/23/23 before the end of the shift. On 6/1/23, the survey day, the facility investigation was not completed and identified as "ongoing" by S1, the Director of Patient Safety and Quality, and S7, the Unit Manager of the Neuro ICU.

On 6/1/23 at 11:15 AM, S7 stated that the facility's initial investigation findings indicated that S11, the RN providing care to P2, used an ice bag containing hot water to apply heat to P2. S7 stated that S11 should not have used an ice bag to apply heat, as the bag is labeled "for ice only." S7 confirmed that S11 failed to follow the physician's order to use warm blankets to maintain P2's body temperature.

On 6/1/23, the facility policy for the treatment of hypothermia was requested. S1 provided a policy on 6/1/23 at 10:55 AM. Review of the policy with S1 and S4 revealed that it was specifically for the Peri-Operative area, and did not apply to the Neuro ICU, the unit where P2 was admitted. On 6/1/23 at 11:00 AM, S1 and S4 confirmed that the policy did not apply to the care administered to P2, and took the policy back. During an interview on 6/1/23 at 11:25 AM, S7 stated that a policy with protocols for maintaining normothermia and treating hypothermia in the ICU units was under development, but had not been completed and approved by the facility.