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Based on interview and record review the facility failed to ensure that 1 of 13 sampled patients (Patient 6) had the right to make an informed decision regarding an invasive diagnostic procedure. This failure had the potential for the patient to have a procedure without understanding the risks and benefits of the procedure.

Findings:

A review on 5/16/12 of the medical record for Patient 6 showed a consent form for a liver biopsy under computerized tomography guidance. There was a section on the form for the physician to indicate that the patient received information regarding the risks and benefits of the procedure, the risk of not performing the procedure, any adverse reactions that may reasonably be expected to occur or any alternative methods of treatment. There was no physician signature, or date and time to indicate that the patient received the information needed to make an informed decision.

There was no documentation in the progress notes by the physician indicating that a informed consent had been obtained.

Patient 6 underwent the procedure on 5/9/12.

In an interview on 5/16/12 at 10:00 AM with the Director of the Medical-Surgical unit, the Director acknowledged that the informed consent should have been done. The Director stated that " At least should have been documented in the progress notes. "

A review of the Medical Staff Rules and Regulations dated 5/12 showed the following:

" No procedures, surgical or otherwise, are to be performed unless the patient or the patient ' s authorized representative has given written informed consent as required by the applicable laws and regulations. It is the treating physician ' s responsibility to obtain and document, in the patient ' s record, the informed consent. "

Based on interview and record review, the facility failed to ensure that a physician assessed and documented an assessment of a hospital acquired pressure ulcer to the coccyx and left heel for 1 of 13 sampled patients (Patient 5).

Findings:

According to the "National Pressure Ulcer Advisory Panel's-Pressure Ulcer Staging Classification Definitions of Pressure Ulcers" and the classification system that the facility used as guidance on their form titled, "Photographic Wound Documentation, PHSI-100-035 (01/12),"
A deep tissue injury was characterized by a purplish or maroon discolored intact area or blood-filled blister due to underlying soft tissue injury.

A Stage 1 was non-blanchable with persistent redness that did not quickly fade and the skin was intact.

A Stage 2 was a partial thickness (tissue loss) which presented as a shallow open ulcer with a red pink wound bed and without slough (black or tan overlay).

A Stage 3 was full thickness tissue loss and subcutaneous fat may have been visible but bones, tendon and muscle were not exposed.

A Stage 4 was full thickness tissue loss with extensive tissue exposure and destruction to muscle, bone or supporting tissues.

An unstageable pressure ulcer was full thickness tissue loss which was covered by a black or tan overlay in the wound area and was unable to be staged until the overlay was removed.

A record review on 5/17/12, at 9:15 AM, of Patient 5, indicated that the patient was admitted on 4/27/12, with a diagnosis of a hip fracture. Patient 5 had surgery on 4/30/12, to repair the fracture.

An interview and a concurrent record review was conducted on 5/17/12, at 9:35 AM, with a Medical Surgical/Telemetry Charge Nurse. He stated that according to Patient 5's initial nursing skin assessment, on 4/27/12, Patient 5's skin was normal and had no pressure ulcers. He also stated that on 4/30/12, a surgical nurse documented, prior to Patient 5's surgery, that the patient had no pressure ulcers and the skin was dry, intact and normal. Additionally, when Patient 5 was transferred from surgery to the Intensive Care Unit (ICU), on 4/30/12, the ICU nurse documented that Patient 5's skin was normal. No pressure ulcers were documented.

A record review and a concurrent interview, on 5/17/12, at 10 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse. The Charge Nurse stated that according to the "Wound Assessment/Photographic Wound Documentation" form, a registered nurse (RN), documented that on 5/1/12, at 4 PM, Patient 5 had a "Brownish discoloration and redness" to the sacrum area (tailbone) that measured 5 x 3 centimeters. In the section, titled "Physician assessment," the physician documented that the pressure ulcer was present on admission. The Charge Nurse stated that according to 3 previous skin assessments conducted on Patient 5's skin, when the patient was admitted, indicated that Patient 5 had no pressure ulcers on admission. The physician indicated that the pressure ulcer was a stage 1. There was no documented evidence that the physician measured the pressure ulcer, there was no documented evidence of a physician description and location of the pressure ulcer and there was no documented evidence that the physician conducted his own assessment of the pressure ulcer. The Charge Nurse stated, that it was unclear when the physician looked at the photograph of the wound because the date was not legible and there was no documented evidence that the physician physically looked at Patient 5's pressure ulcer or if he just looked at the photograph that nursing took of the pressure ulcer.

A record review and a concurrent interview, on 5/17/12, at 10:40 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse, of Patient 5's wound assessment dated 5/5/12. The photograph was of Patient 5's coccyx region, which appeared dark purple with an area that was dark brown/black and the area around the pressure ulcer was red. There were no measurements or descriptions of the pressure ulcer and was not staged. The "Physician Assessment" section contained a physician's signature, however it did not contain the physician's assessment of Patient 5's pressure ulcer and it was not dated or timed. Additionally, there was no documented evidence in the medical record that Patient 5's physician performed an assessment or looked at the pressure ulcer. The Charge Nurse stated that he was unable to find a physician assessment of Patient 5's pressure ulcer.

A record review and a concurrent interview, on 5/17/12, at 10:40 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse, of Patient 5's wound assessment and photograph dated 5/6/12, at 5:13 AM. An RN documented that Patient 5 had a wound on the coccyx region. The staging of the wound was not documented and there were no measurements documented. The photograph showed an open area however the majority of the area that surrounded the open sore was covered with a dark blackish/brown overlay and had redness around the dark area. The picture, showed an unstageable pressure ulcer, according to the Charge Nurse. A second picture was also taken of Patient 5's left heel. The RN documented that it was an "Unstageable Pressure Ulcer." The "Physician Assessment" section contained a physician signature however it had no date or time and no physician assessment of the pressure ulcers. The physician documented that the pressure ulcer on the coccyx was not present on admission and that it was a "skin tear." The Charge Nurse stated that he was unable to find a physician assessment of the pressure ulcers.

A record review and a concurrent interview, on 5/17/12, at 10:55 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse, of Patient 5's "Wound Assessment/Photographic Wound Documentation," dated 5/13/12, at 3 PM. An RN who was covering for a Wound Care Nurse, conducted the assessment and documented that Patient 5 had a wound to the sacrum area. There was no staging of the pressure ulcer documented. The picture showed a large pressure ulcer that was open and had dark discoloration around the open area. The "Physician Assessment" section, contained a physician's signature however the Charge Nurse could not read the date or time and the physician's assessment was left blank. The Charge Nurse stated that he could not find a physician assessment of the pressure ulcer.

A record review and a concurrent interview, on 5/17/12, at 10:55 AM, was conducted with a Medical Surgical/Telemetry Charge Nurse, of Patient 5's "Wound Assessment/Photographic Wound Documentation," dated 5/13/12, at 10 PM of the left heel. The RN did not stage the pressure ulcer. The picture showed a large dark purple and red pressure ulcer that covered the entire area of the heel. The "Physician Assessment" section, contained a physician's signature however the Charge Nurse could not read the date or time and the physician's assessment was left blank. The Charge Nurse stated that he was unable to find a physician assessment of the pressure ulcer.

A record review, on 5/17/12, at 3 PM, of the facility's "Medical Staff Rules and Regulations," documented the following: "...All practitioners understand and accept the principle that Hospital Medical staff privileges are dependent upon individual skill and training and not solely on licensure. The primary responsibility of a practitioner is to render medical care to the sick and injured persons who have selected him or her as their practitioner, or who have been placed in his or her care by a responsible agent. In discharging this responsibility he or she brings to bear all his or her medical skill and judgment ..."

Based on interview and record review, the facility failed to ensure that a Registered Nurse who was covering for a Wound Care Nurse and conducting wound assessments of patients, was adequately trained and competent to care for patients who required "Wound Care Evaluations." This failure resulted in 1 of 13 sampled patients (Patient 5), to not receive the appropriate care and necessary services from a Wound Care Nurse, which was ordered by the physician.

Findings:

A record review, on 5/17/12, at 9:15 AM, of Patient 5, indicated that the patient was admitted on 4/27/12, with a diagnosis of a hip fracture. Patient 5 had surgery on 4/30/12, to repair the fracture.

A record review, on 5/17/12, at 10:40 AM, of Patient 5's "Wound/Skin Care Physician Orders," dated 5/6/12, indicated that Patient 5's physician ordered a "Wound Care Evaluation" for the patient.

A record review, on 5/17/12, at 10:55 AM, of Patient 5's "Wound Assessment and Photographic Wound Documentation," dated 5/13/12, at 3 PM, indicated that a RN conducted the assessment however there was no staging of the pressure ulcer.

An interview and a concurrent record review, on 5/17/12, at 10:55 AM, of Patient 5's medical record was conducted with a Medical Surgical/Telemetry Charge Nurse. After reviewing Patient 5's medical record, the Charge Nurse stated that the usual Wound Care Nurse (who had taken time off from work) and who conducted the Wound Care Evaluation of Patient 5, was being covered by a RN who was not a Wound Care Nurse. The Charge Nurse also stated that the reason the RN did not stage the pressure ulcer was because, according to the facility policy, only Wound Care Nurses and physicians, can stage a pressure ulcer. He also stated that the RN who conducted the evaluation, was a floor/staff RN and was not allowed to stage the pressure ulcer. He stated that no "Wound Care Evaluation" was done for Patient 5 by a Wound Care Nurse, until 5/16/12.

An interview and a concurrent record review was conducted on 5/16/12, at 3 PM, with the facility Administrative Assistant, of the personnel file of the RN who performed the Wound Care Evaluation on Patient 5. The Administrator Assistant stated that the RN did not have a job description in her file to indicate that she was competent to perform Wound Care Evaluations.

Based on interview and record review, the facility failed to ensure that a Registered Nurse (RN) did not write a physician order without speaking with and obtaining the order from the physician. This failure contributed to the potential for an increased risk for 1 of 13 sampled patients, (Patient 3), to not receive medical treatment as intended by the patient's primary care physician.

Findings:

A record review, on 5/15/12, at 11 AM, indicated that Patient 3 was admitted to the telemetry floor (a unit that provides cardiac monitoring), on 5/14/12, with a diagnosis of congestive heart failure (heart disease).

A record review, on 5/15/12, at 11 AM, of Patient 3 s initial "Wound Assessment and Photographic Wound Documentation," dated 5/14/12, at 4:30 PM, indicated that a LVN (Licensed Vocational Nurse) performed the initial skin assessment of Patient 3. The picture showed a large red pressure ulcer around Patient 3's coccyx area with a small open sore (Stage 2).

A record review, on 5/15/12, at 11 AM, of Patient 3's physician orders (not dated or timed), indicated that Patient 3 had a Stage 2 pressure ulcer. The orders, read to cleanse the pressure ulcer with normal saline, apply comfeel (pressure ulcer dressing) to the wound every 2 days. The order also included, a wound care evaluation, specialty mattress/pressure redistribution support surface: (Isoflex), reposition every 2 hours as condition permits and to redistribute pressure with pillow/wedges.

An interview, on 5/15/12, at 3 PM, was conducted with the Wound Care Nurse who wrote the physician orders. She stated that it was her first day working at the facility and that she was covering for the facility Wound Care Nurse who had taken some time off from work. She stated that she did write the order but that she had not spoken with the physician. The Wound Care Nurse also stated that she was told by the facility staff, "That's how they do it here."

A record review, on 5/16/12, at 8:25 AM, of the facility policy, titled "Verbal and Telephone Orders, dated September 2011," indicated the following: "...Orders given verbally or by telephone for medications and their administration shall be filled only when given by a qualified physician...All verbal/telephone orders of medication shall be transcribed in writing into the medical chart of the patient form if taken...To prevent medication errors related to verbal/telephone orders, all individuals licensed and approved by this hospital to receive and record these types of orders must strictly observe the following practices when performing this function. The receiver of the order must:...Write down the complete order and then read it back to the prescriber, receiving confirmation from the prescriber that the order is correct...Read the entire order to the prescriber..."

Based on record reviews and interviews, the hospital failed to ensure that the diets served to 2 of 3 patients reviewed for nutrition care were consistent with the physician ordered diets (Patients 9 and 10). For Patient 9, the physician ordered "Diet as Tolerated, ADA restrictions (diabetic)" and the diet served was an "1800 calorie ADA" diet. For Patient 10 the physician ordered a Regular diet and the patient was served a Renal diet (for patients with impaired kidney function). This failure to ensure that patients received the physician ordered diets had the potential for the nutrition needs of the patient to not be met and further compromise their medical status.

Findings:

1. A review of the medical record for Patient 9 revealed a physician order dated 5/12/12 for "Diet as Tolerated, ADA restrictions." There was no calorie limit element to the diet order.

A review of Food and Nutrition Services Current Diet list showed that Patient 9's diet listed as 1800 Calories ADA diet.

During an interview with the Registered Dietitian (RD) on 5/15/12 at 2:15 pm, she verified that the patient was receiving an 1800 calorie ADA diet. She further verified that the physician's diet order did not specify a calorie restriction. She stated that the order was entered into the computer system incorrectly. She stated that the patient was receiving the incorrect diet order for 3 days. She stated that she monitors the diet orders for the patients that are reviewed for nutrition assessments by the RD, but not the patients who were not considered high nutrition risk. Those patients are not required to be reviewed by the RD until 5 days after they are admitted.

During an interview with RN 1, charge nurse for Patient 9, on 5/15/12 at 2:20 pm, she stated that the diet order had been entered in the computer system incorrectly. It should have entered as "ADA, Calories Not Specified". She was unable to explain why the incorrect diet order was not noted for 3 days

2. A review of the medical record for Patient 10 revealed that there was a physician order for a Regular diet on 5/7/12.

A review of Food and Nutrition Services Current Diet list showed that Patient 10's diet listed as Renal diet. Renal diets are restricted in sodium, potassium and phosphorus for patients with impaired kidney function.

During an interview with the RD on 5/15/12 at 3:30 pm, she verified that the patient was receiving a renal diet since 5/13/12. She stated that the patient should have been receiving a regular diet. She stated that the incorrect diet was entered in the computer system.

During an interview with RN 1, charge nurse for Patient 10, on 5/15/12 at 3:45, she was unable to explain why the order in the computer was changed from a regular to a renal diet when the physician order did not change. She was also unable to explain why the error was not noted for two days.

Patient who receive inaccurate diets are at risk for nutritional deficits, especially when the diets served are more restrictive than the physician order.