HospitalInspections.org

Based on record review, staff interviews and review of policy and procedures the facility failed to:
Part I - Ensure 4 of 20 patients (Patient 11, 13, 15, and 16) were provided activity of daily living needs including bathing and/or mobility and/or failed to assess wounds and provide wound care as ordered; and
Part II- Ensure 1 of 20 patients (Patient 11) receiving intravenous (IV) (fluids/medication flowing into the vein via a tube or syringe) therapy received nursing assessments and interventions to treat infiltration (fluid leaking into the tissue at the site of the IV) of IV fluid/medication and documentation of assessments and interventions in accordance with the facility policy and procedures. The facility census was 69.

Findings are:

PART I:
A. A review the medical record for Patient 11 (admitted 9/12/17 and discharged 9/19/17) following hospitalization for sepsis revealed that the record lacked documentation of Patient 11 receiving a bath on 9/12/17, 9/13/17, 9/14/17, 9/15/17, 9/16/17 and 9/17/17. The record documented that Patient 11 received a bath on 9/18/17 and 9/19/17.

B. A review of the medical record for Patient 13 [admitted 9/12/17 for acute cystitis (a sudden inflammation of the bladder usually caused by an infection) and chronic congestive heart failure (fluid build up around the heart causing it to pump inefficiently) and dismissed on 9/19/17 to a nursing home], revealed that the record lacked documentation of receiving a bath on 9/16/17, 9/17/17, 9/18/19, and 9/19/17; the patient refused a bath on 9/13/17 and 9/15/17. The record documented that Pateint 13 received a bath on 9/14/17.

Patient 13's medical record also noted that on 9/12/17, 2 areas were noted on the patients skin:
- Area 1 was described as a Stage I PU (pressure ulcer-a non blanchable redness of intact skin [a red area due to the presence of red blood cells outside of the blood vessel] ) on Patient 13's left upper thigh;
-Area II was described as a Skin Tear (a separation of the layers of the skin due to some kind of trauma to the area) - it did not identify the location. There was no further documentation about the skin tear in the medical record.

The medical record failed to demonstrate nursing staff consistently assessed and monitored the areas of skin breakdown to evaluate if additional intervention were need to promote healing.

Documentation in the medical record further revealed:
-Charting on 9/13/17 at 1638 (4:38 PM) revealed, left buttock red but blanchable (a red area that loses all redness when pressed)
-no further charting on the left buttock (left upper thigh) noted on 9/14/17, 9/15/17, 9/16/17, 9/18/17
-Charting on 9/19/17 at 0815 (8:15 AM) revealed, Purple redness L) (left) ankle, wound left outer buttock.

The medical record failed to demonstrate nursing staff consistently assessed, monitored, measured and/or described the areas of skin breakdown to evaluate if additional intervention was need to promote healing.

An interview with RN B at 10:15 AM on 9/19/17 revealed, that Patient 13 was currently being discharged and transported to a nursing home. RN B described the left ankle area as "an ankle discoloration on the top of the foot/ankle area." RN B described the left outer buttock wound as "Well it is beginning to be an ulcer, that is why we are using barrier cream on it and have a waffle mattress and turning the patient every 2 hours."

A review of the medical record for Patient 13 revealed, charting on 9/14/17 and 9/15/17 of the patient being repositioned every 2-3 hours; on 9/16/17 from 7:40 PM until 7:30 AM there was no charting related to the patient being repositioned or turned; On 9/17/17 there was no charting related to repositioning or turning after 7:30 AM; and on 9/18/17 at 8:57 PM the patient refused to be turned and at 9:03 PM the patient was repositioned, there is no further charting related to repositioning noted in the record.

An interview with the Clinical Practice Coordinator (CPC) on 9/19/17 at 10:30 AM revealed, "I assume that the skin area described as left upper thigh on admission is the same area as the area described as left outer buttock."

C. A review of the medical record for Patient 15 admitted 9/3/17 for psychosis (an abnormal condition of the mind that involves a loss of contact with reality) and urinary retention (inability to partially or totally empty the bladder) revealed the record lacked documentation of receiving a bath on 9/3/17, 9/4/17, 9/5/17, 9/6/17, 9/7/17, 9/9/17, 9/10/17, 9/12/17, 9/13/17 and 9/18/17. The record documented that Patient 15 refused a bath on 9/8/17, 9/11/17, 9/14/17, 9/15/17, 9/16/17, 9/19/17 and 9/20/17; this documentation demonstrates that the patient has not had a bath since admission on 9/3/17. The record lacked teaching on the importance of bathing or strategies for ensuring bathing throughout the hospital stay.

Patient 15's medical record also noted that on 9/3/17, 2 open areas were noted on the patients skin:
- Area 1 was described as wound to the right knee, the chart lacked descriptive documentation of this area.
-Area II was described as a blister to the left knee. On 9/7/17 documentation revealed that the left knee blister area resolved.

The medical record failed to demonstrate nursing staff consistently assessed, monitored, measured and/or described the areas of skin breakdown to evaluate if additional intervention was need to promote healing

Follow up charting on Patient 15's integumentry (skin) flow sheet regarding the wound to the right knee noted on 9/3/17 admission documentation revealed:
-9/5/17 abrasion to right knee
-9/7/17 excoriation to right knee
-9/8/17 at 3:15 PM the Wound Nurse saw Patient 15 for a consultation, the consultation revealed, "The ulcer is characteristic of wound from fall x 2 located right knee. The upper wound measures 0.7 cm (centimeters) x 1.0 cm x 0.2 cm and the lower wound measures 3.7 cm x 4.2 cm x 0.2 cm. The ulcer is considered Partial-thickness. The ulcer bed is described as containing pink granular and red granular and has no exposed subcutaneous tissue, muscle, tendon and bone. the skin around the ulcer is dry, intact, and normal. There is minimal amount of serosanguinous exudate (thin, watery, pale red to pink drainage) draining from the ulcer. The patient describes the pain as 1/10."
The Wound Care ordered is 1) Every 2 days and PRN (as needed)-right knee wounds, cleanse with normal saline, pat dry. Cut Aquacel AG (a wound dressing that is absorbent and has an antimicrobial barrier) to slightly larger than wound bed, moisten with normal saline, cover with 5x5 Aquacel Foam with adhesive border- change PRN. 2) Edema Wear-do not cut edema wear. Place edema wear on bilateral legs. Ensure at least a 1 inch cuff at the top and at the toes to prevent rolling and a tourniquet occurring. Monitor skin under edema wear every shift. 3) Follow Pressure Prevention Measures- frequent turns/repositioning, moisturize intact skin, use of Aloe Vesta Protectant Ointment to buttocks/coccyx BID (twice a day) and PRN, elevate heels/elbows, use of heel protectant boots...4) Wound care to follow 1-2 times a week.
-9/9/17 aqualcel dressing charted
-9/10/17 dressing changed
-9/11/17 and 9/12/17 no charting on dressing and was not changed on 9/12/17 (2nd day)
-9/13/17 dressing reinforced
-9/14/17 no charting and was not changed
-9/15/17, 9/16/17 the dressing was changed.
-9/17/17 and 9/18/17 no charting and dressing was not changed on 9/18/17 (2nd day)
-9/19/17 dressing changed

An interview with the Clinical Practice Coordinator (CPC) on 9/19/17 at 11:05 AM revealed that the order for the dressing and the instructions on when and how to change the dressings does not appear on the Medication Administration Record or on a treatment task list, the nurse is supposed to document the dressings on the integumentary flow sheet. The CPC verified the order was to change the dressing every 2 days and PRN and that "there was no documentation of the dressing being changed from 9/10/17 until 9/15/17." "The only measurements of the wounds was done by the Wound Nurse on 9/8/17."

Wound measurements enable the nursing staff to assess and monitor the wound for evidence of healing or expansion/worsening of the wound.

D. A review of the medical record for Patient 16 admitted 7/23/17 for a small bowel obstruction, diabetes and stage V renal failure (advanced kidney disease when the kidneys have lost nearly all their ability to do their job effectively) and dismissed on 8/4/17 to a nursing home, revealed the record lacked documentation of Patient 16 receiving a bath on 7/23/17, 7/24/17, 7/25/17, 7/28/17, 7/29/17, 7/30/17, 8/3/17 and 8/4/17; the patient refused a bath on 7/26/17, 7/28/17 and 7/31/17. The record documented that Pt 16 received a sponge bath on 8/1/17 and 8/2/17 from the Occupational Therapist.

Patient 16's medical record also noted that the integumentery flow sheet identified the following areas of the skin:
-7/23/17 at 1545 (3:45 PM) Bilateral arm bruising; abrasion right foot 4th toe, skin tear (ST) elbow. 2033 ST right elbow, scattered bruising.
-7/24/17 at 4:17 AM bruising, ST, no change
-7/25/17 no documentation on integumentery flow sheet
-7/26/17 at 1945 (7:45 PM) Heels off bed, scattered, general
-7/27/17 at 4:05 AM, 3:57 PM and 8:50 PM scattered bruising, general
-7/28/17 at 4:05 AM and 8:05 AM scattered bruising, general
-7/29/17 at 1533 (3:33 PM) bilateral lower extremity edema- 2+ (mild) right lower extremity and 2+ left lower extremity, bruising; abrasion; 2026 (8:26 PM) heels off bed
-7/30/17 at 7:30 AM and 9:30 AM bruising; abrasion, scattered bruising, abrasion to right foot-4th toe, skin tear to right elbow, bilateral lower extremity edema- 2+ right lower extremity and 2+ left lower extremity
-7/30/17 at 2043 (8:43 PM) and 3:44AM bilateral lower extremity edema- 2+ right lower extremity and 2+ left lower extremity, bruising; abrasion, scattered bruising, abrasion to right foot-4th toe, abrasion to right elbow
-7/31/17 at 7:26 AM and 1529 (3:29 PM) bilateral lower extremity edema- 1+ (trace) right lower extremity and 2+ pitting left lower extremity, bruising; abrasion,
-8/1/17 at Midnight and 3:25 AM bilateral lower extremity edema- 1+ right lower extremity and 2+ left lower extremity, bruising; swelling;
-8/1/17 at 7:35 AM and 1623 (4:23 PM) bilateral lower extremity edema- 1+ right lower extremity, 2+ left lower extremity pitting, bruising; swelling
-8/1/17 at 2011 (8:11 PM) bilateral lower extremity edema- 2+ non pitting right lower extremity and 4+ pitting (severe) left lower extremity,bruising; swelling; abrasion, abrasion to 4th digit of right foot; bruises to bilateral arms; swelling to bilateral lower extremities and penis, swelling of male genitalia-penis, bilateral edema wear on
-8/2/17 at 2:48 AM bilateral lower extremity edema- 2+ non pitting right lower extremity and 4+ pitting (severe) left lower extremity, bruising; swelling; abrasion,
-8/2/17 at 8:19 AM bruising; swelling; abrasion
-8/2/17 at 1641 bilateral lower extremity edema 1+, bruising; swelling; abrasion, abrasion to 4th digit of right foot; bruises to bilateral arms; swelling to bilateral lower extremities and penis, swelling of male genitalia-penis, bilateral edema wear on
-8/3/17 at 2028 and 3:31 AM bilateral lower extremity edema 2+ bruising; swelling; abrasion-no change from previous assessment, swelling of male genitalia-penis; bilateral edema wear on
-8/3/17 at 8:41 AM and 1523 (3:23 PM) bruising; swelling; abrasion, swelling of male genitalia, bilateral lower extremity edema 1+, bilateral edema wear on
-8/3/17 at 2103 (9:03 PM) and 2311 (11:11 PM) bruising; swelling; abrasion, swelling of male genitalia, bilateral lower extremity edema 1+
-8/4/17 9:18 AM general bruising, abrasion to R foot/toes, skin tear to elbow, bruising; swelling; abrasion, bilateral lower extremity edema 1+; swelling of male genitalia, uses urinal

The medical record failed to demonstrate nursing staff consistently assessed, monitored, measured and/or described the areas of skin breakdown to evaluate if additional intervention was need to promote healing.

A review of the Nursing Skin Check Flowsheet dated 8/4/17 at 1655 (4:55 PM) at the receiving facility identified redness to the right heel and left outer ankle on admission.

E. A review of the facility Skin Assessment- Pressure Ulcer, Braden Scale and Wound Policy and Procedure identified as Policy Stat ID: 2907374 with last review date of 12/2017 revealed:

BASELINE ASSESSMENT:
-Documentation of a pressure ulcer may include: location; surface dimension-length, width, and depth of wound in centimeters; presence of granulation tissue (new tissue forming), necrotic tissue, undermining, tunneling, fibrin; drainage, condition of surrounding skin and wound margins, dressing type and wound base status.
-If a wound exists: measure length by width by depth and describe; undermining is measured with a cotton-tipped applicator; tunneling is measured; call the wound care clinic when appropriate; update patient's care plan.

F. A review of the facility Chlorhexidine Gluconate (CHG) Bathing-Daily and Preoperative Skin Prep identified as Policy Stat ID: 3907096 with last review date of 8/2017 revealed:
-Bathing with CHG reduces the risk of infection. It is provided in a package of 6 cloths.
-CHG is contraindicated for use on: mucous membranes, e.g., genitals, mouth, eyes, and ears; Children less than 2 months old, including infants in NICU (neonatal intensive care unit); patients with a chlorhexidine sensitivity.
-CHG bathing does not replace soap and water cleaning for required perineal and facial care.

G. An interview with the Vice President of Patient Care on 9/20/17 at 8:30 AM revealed the facility had no other bathing, hygiene or activities of daily living policies and procedures.

PART II:
A. A review the medical record for Patient 11 (admitted 9/12/17 and discharged 9/19/17) following hospitalization for sepsis (The body's extreme response to an infection which can be life threatening.) Review of the Infusion Site Therapy flow sheet showed that on 9/12/17 an IV was started in Patient 11's left forearm, and Patient 11 received an IV of 5% dextrose in half strength normal saline (D5 1/2NS) running at 100 cc/hr (cubic centimeters per hour) via an IV pump. On 9/14/17 at 2100 (9:00 PM) Registered Nurse (RN) S documented on the Infusion Site Therapy flow sheet that the IV site was tender, red and infiltrated. The medication administration record showed that Ancef (Piperacillin and Tazobactam an IV antibiotic) 4.5 gm (grams) was infusing at 25cc/hr. The IV was discontinued and an ice pack was applied.

Review of the facility policy named "Extravasation of Intravenous Fluids/Medications" with the Policy Stat ID: 3414742 (last revised 04/2017) revealed:

POLICY:
-Definitions -1) Extravasation - inadvertent leakage or infiltration of intravenous or intra-arterial fluids into interstitial tissue. 2) Vesicant - any agent (medication) capable of causing a blister and/or tissue damage or causing local or extensive tissue necrosis (death) with or without ulceration. The irritants can result in pain at the IV site and along the vein and may or may not cause inflammation. Extravasation can result in tissue sloughing, pain, loss of mobility in the extremity and infection. The treatment for extravasation will vary depending on the antidote for the infiltrated medication and your facility policy.
-Antidotes and treatment of extravasation need to be initiated within an hour of discovery.

MISCELLANEOUS AGENTS- Piperacillin/tazobactam (Zosyn - medication utilized to treat a variety of bacterial infections); ANTIDOTE- No specific antidote necessary; The policy identified the procedure to treat infiltration/extravasation of the antibiotic Piperacillin/tazobactam. The procedure was to stop the fluid infusion immediately and per the policy to "Apply warm compress 20 minutes QID (4 times a day) x (by) 48 hours. Elevate extremity for 48 hours".

The medical record failed to demonstrate staff provided Patient 11 treatment for the infiltrated medication Piperacillin/tazobactam (Zosyn - a medication utilized to treat a variety of bacterial infections) in accordance with the facility policy by placing an ice pack on Patient 11's forearm.

An interview with the Quality Improvement Coordinator on 9/20/17 at 10:35 AM verified that there was no further assessment, monitoring or treatment of the IV site and that facility policy was not followed.

Based on record reviews and review of facility policy and procedures, the facility failed to keep current the plan of care updated and current for 4 of 20 sampled patients (Patient's 11, 13, 15 and 16) related to Activity of Daily Living (ADL) needs (bathing and mobility) and/or skin assessment and treatments. Facility census was 69.

Findings are:

A. A review of the medical record for Patient 11 (admitted 9/12/17 and discharged 9/19/17) following hospitalization for sepsis (The body's extreme response to an infection which can be life threatening.) identified the Plan of Care and interventions for this patient as: safety risk, altered nutrition and fall risk.

The medical record lacked a Plan of Care for:
-Alteration in Activity of Daily Living related to: The patient did not receive a bath 6 of 7 days while in the hospital with no mention of an assessment of the level of assistance Patient 11 needed, education and/or interventions the facility implemented to address the problem of the patient's lack of bathing.

B. A review of the medical record for Patient 13 admitted 9/12/17 for acute cystitis (a sudden inflammation of the bladder usually caused by an infection) and chronic congestive heart failure (fluid build up around the heart causing it to pump inefficiently) and dismissed on 9/19/17 to a nursing home, identified the Plan of Care and interventions for this patient as: pain, safety risk, and fall risk.

The medical record for Patient 13 lacked a Plan of Care for:
-Alteration in Activity of Daily Living related to: The patient did not receive a bath 6 of 7 days while in the hospital with no mention of an assessment of the level of assistance Patient 13 needed, education and/or interventions the facility implemented to address the patient's problem of lack of bathing.
-Alteration in Skin Integrity related to: The patient was identified with a Stage I pressure ulcer on left upper thigh and a skin tear (a separation of the layers of the skin due to some kind of trauma to the area) on admission. The record did not address an assessment of skin integrity, interventions to heal and prevent other skin issues including repositioning/getting out of bed (mobility) and/or patient education related to skin integrity. The chart also did not update the assessment and monitoring of the patient's infiltration of the Ancef at the IV site and the need to warm pack the area 4 times a day for 48 hours (in accordance with the facility policy and procedure).

C. A review of the medical record for Patient 15 admitted 9/3/17 for psychosis (an abnormal condition of the mind that involves a loss of contact with reality) and urinary retention (inability to partially or totally empty the bladder). The medical record identified the Plan of Care and interventions for this patient as: pain, safety risk, and infection risk.

The medical record for Patient 15 lacked a Plan of Care for:
-Alteration in Activity of Daily Living related to: The patient did not receive a bath 17 of 17 days while in the hospital with no mention of the level of assistance Patient 15 needed, education and/or interventions the facility implemented tried to address the problem of lack of bathing.
-Alteration in Skin Integrity related to: The patient was identified with a wound to the right knee and a blister to the left knee on admission. The record did not address skin integrity interventions to heal and prevent other skin issues, including assessments, treatments and/or patient education related to skin integrity.
-Alteration in Behavior related to psychosis: It was documented in the charting that the patient was frequently uncooperative and would occasionally throw objects and act out. The Plan of Care lacked any assessments and/or interventions regarding this patients behaviors.

D. A review of the medical record for Patient 16 admitted 7/23/17 for a small bowel obstruction, diabetes and stage V renal failure (advanced kidney disease when the kidneys have lost nearly all their ability to do their job effectively) and dismissed on 8/4/17 to a nursing home, identified the Plan of Care and interventions for this patient as: pain, safety risk, fall risk, alteration in nutrition and an alteration in gastrointestinal functions.

The medical record for Patient 16 lacked a Plan of Care for:
-Alteration in Activity of Daily Living related to: The patient did not receive a bath 10 of 12 days while in the hospital with no mention of an assessment of the level of assistance Patient 16 needed, education and/or interventions implemented to address the problem of the patients' lack of bathing.
-Alteration in Skin Integrity related to: The patient was identified with an abrasion to right foot/4th toe, scattered bruising and a skin tear to the right elbow on admission. The record did not address an assessment of skin integrity, interventions to heal and prevent other skin issues including repositioning/getting out of bed (mobility) and/or patient education related to skin integrity. In addition, the dismissal paperwork for Patient 16's transfer to the nursing home lacked mention of the patient's skin integrity issues.

E. Review of the policy and procedure for Skin Assessment: Pressure Ulcer, Braden Scale and Wound Policy and Procedure identified as Policy Stat ID: 2907374 (with last review date of 12/2017) revealed, "To update the plan of care to reflect risk of skin breakdown. Update patient's plan of care to include Potential/Actual impaired Skin integrity."

F. Review of the policy and procedure for Plan of Care identified as Policy Stat ID: 4019868 (with last review date of 9/2017) revealed:
-All Patients will receive planned nursing care under the direct supervision of the RN. (Registered Nurse)
-Patient's plan of care goals are based on the nursing assessment which is realistic, measurable, and consistent with therapy prescribed.
-Actual and potential health problems identified as having the potential to be resolved through actions or interventions of the health care team will be identified on the patient's Interdisciplinary Plan of Care.
-The clinical care provided to patients will be based on established standards of patient care that reflect needs or problems as documented on the plan of care.
-The patient and/or family/significant other will be involved in the patient's care, as appropriate through inclusion in activities, which may include, but are not limited to, interviews, participation in care or education, care conferences, and discharge planning conferences.
-Nurses will review documentation by other disciplines and actively involve other members of the health care team in discussions about patient care problems/needs and in discharge plans.
-Discharge planning will begin upon admission and continue throughout the hospital stay.