HospitalInspections.org

Based on interview, record review, and policy and procedure review the Hospital failed to ensure each patient was informed of their Patient Rights upon admission for one (1) of 20 medical records reviewed (Patient #1) and failed to ensure each patient consented to care for five of twenty medical records reviewed (Patients #16, #17, #18, #19, #20). This deficient practice puts all patients at risk for failing to receive care and consent to that care according to their personnel convictions and choices.

Findings Include:

- Patient #1's medical record reviewed 10/16/2017 revealed the medical record lacked evidence Patient #1 or his/her durable power of attorney (DPOA) received notification of patient rights and consent to treat throughout his/her hospitalization. Patient #1 was confused at the time of admission on 6/26/2017 and was unable to sign for Patient Rights and Consent to treat.

Document titled "Previous Encounter Comments" revealed documentation on 6/27/2017 at 4:27pm by Staff QQ the "patient sleeping and did not respond to name being called.", on 6/29/2017 at 12:44pm by Staff RR "patient did not wake up when called...", on 7/1/2017 at 12:59pm by Staff SS "Patient was asleep, no family in room, unable to register", on 7/2/17 at 2:58pm by Staff SS "Patient not in room, no family, left letter, unable to register".

- Medical record review on 10/17/2017 at 8:00AM revealed 5 (five) of 20 records (Patients #16, #17, #18, #19, and #20) failed to document Admission consent.

Staff X, interviewed on 10/17/2017 at 9:30AM with clinical informatics specialist confirmed "it's not here".

Based on record review, policy review and staff interview, it was determined that the Hospital failed to ensure nursing staff developed and kept current a nursing care plan for potential alteration of skin integrity for 6 of 20 medical records reviewed (Patients #1, #2, #3, #4, #7, #12, and #13) who were assessed at risk for alteration of skin integrity with potential for skin breakdown. This deficient practice has the potential to place patients at an increased risk for injury, illness, or death.

Findings include:

- Patient #1's medical record review on 10/17/2017 revealed a date of birth 11/28/1925, s/he was admitted to the emergency department (ED) on 6/26/2017 with acute hypoxia and respiratory failure. Following ED assessment s/he was admitted to the medical intensive care unit (MICU) on 6/26/2017. The patient has a past medical history of thyroid disease, bulimia and dementia presenting with fever, congestion, and cough and a diagnosis of sepsis (sepsis occurs when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body. This can cause a cascade of changes that damage multiple organ systems, leading them to fail, sometimes even resulting in death. Symptoms include fever, difficulty breathing, low blood pressure, fast heart rate, and mental confusion) secondary to pneumonia. The nursing care plan documentation on 6/26/2017 by Staff RN II revealed the patient was placed on pressure ulcer prevention with verbalization of understanding.

- Documentation of the Braden Scale (a total score of 23 places the patient at no risk and a score of 6 places a patient at seriously high risk for pressure ulcer development) is used as a predictor of pressure ulcer risk for all patients. Patient #1 had a Braden Score of 17 on admission 6/26/2017

-Score of 17 on 6/26 at 5:00 pm
-Score of 15 on 6/26 at 8:00 pm
-Score of 14 on 6/27 at 8:00 pm
-Score of 11 on 6/28 at 9:00 pm and 12:00 pm
-Score of 13 on 6/29 at 8:30 pm and 12:00 pm
-Score of 12 on 6/30 at 9:23 am
-Score of 9 on 7/2 at 9:00 am 7/1 at 11:55 pm
-Score of 10 on 6/30 at 9:22 pm, 7/1, 7/2, 7/3, 7/4, and 7/5.

- Nursing Staff documentation of the following patient position changes were recorded with the head of the bed elevated at 30-45 degrees. Time noted in parenthesis indicates the amount of time between nursing staff documentation of patient position changes.

6/26/17 - 10:00pm
6/27/17 - 8:52am (11.75 hours), 11:00pm (13 hours)
6/28/17 - 3:00am (5 hours), 8:00pm (17 hours)
6/29/17 - 4:50pm (8.75 hours), 9:00pm (4 hours), 11:00pm
6/30/17 -3:00am (4 hours), 11:00am (8 hours), 8:00pm (9 hours), 10:00pm (8.75 hours)
7/1/17 - 6:50am, 12:30pm 5.5 hours), 4:37pm, 8:00pm 3.5 hours), 10:00pm
7/2/17 - 4:00am (5 hours), 6:00am, 9:00am (3 hours), 11:00am
7/3/17 - 9:00pm (10 hours), 11:13pm (2.25 hours)
7/4/17 - 2:00am (2.45 hours), 4:00am, 7:40am (3.7 hours), 9:30am, 3:00pm (5.5 hours), 5:00pm, 10:00pm (5 hours)
7/5/17 - 2:00am (4 hours), 4:00am,

- Patient Position documentation revealed the nursing staff failed to document the patient's position every two hours.


- Patient #12's medical record review on 10/17/2017 revealed they were admitted to the 7N medical-surgical unit on 9/27/2017 and discharged on 10/3/2017 with a diagnosis of a Pressure Ulcer. The medical record lacked evidence staff followed the nursing care plan that was initiated at admission and updated it throughout the hospitalization and failed to follow their pressure ulcer protocol.

- Documentation in the medical record identified Skin Integrity as an identified patient problem and an intervention documented required the patient to be repositioned every two hours.

- Infectious Disease Consultation Notes by Physician Staff N reviewed on 10/17/2017 at 3:30 PM revealed the plan for the patients care included "Continue pressure ulcer protocol - strict offloading, PT/OT, specialty bed, roho cushion when OOB (Out of Bed), tobacco/nicotine abstinence, optimize nutrition, glucose control, and prevent wound contamination w/ urine/stool/incontinence".

- Patient Position documentation revealed the nursing staff failed to document the patient's position very two hours. Position Documentation was recorded as follows:

9/27/2017 at 8:49 PM the patient's position was recorded as Head of Bed elevated 30-45 degrees. The next documentation of positioning did not occur until 9/28/2017 at 12:20 PM (16 hours and 29 minutes later) recording the patient's position as Head of Bed elevated 30-45 degrees. At 8:20 PM (9 hours later) the patient's position was recorded as Supine (on their back), Head of Bed elevated 30-45 degrees.

9/29/2017 at 9:00 AM (13 hours and 20 minutes after the last position entry), the patient's position was recorded as Supine, Head of Bed elevated 30-45 degrees. At 2:10 PM (5 hours and 10 minutes after the last position entry), the patient's position was recorded as Supine, Head of Bed elevated 30 degrees or less. At 5:00 PM (2 hours and 50 minutes after the last position entry), the patient's position was recorded as Head of Bed elevated 30 degrees or less. At 8:00 PM (3 hours after the last position entry), the patient's position was recorded as laying on the left side, Head of Bed elevated 30-45 degrees.

9/30/2017 at 8:00 AM (12 hours after the last position entry), the patient's position was recorded as Head of Bed elevated 30 degrees or less. At 12:50 PM (4 hours and 50 minutes after the last position entry), the patient's position was recorded as Head of Bed elevated 30 degrees or less. At 4:41 PM (3 hours and 51 minutes after the last position entry), the patient's position was recorded as Head of Bed elevated 30 degrees or less. At 8:00 PM (3 hours 19 minutes after the last position entry), the patient's position was recorded as Head of Bed elevated 30 degrees or less.

10/1/2017 at 8:00 AM (12 hours after the last position entry), the patient's position was recorded as Head of Bed elevated 30-45 degrees. At 12:00 PM (4 hours after the last position entry), the patient's position was recorded as Head of Bed elevated 30-45 degrees.

10/2/2017 at 9:15 PM (33 hours and 15 minutes after the last position entry), the patient's position was recorded as lying on the left side.

10/3/2017 At 8:00 AM (10 hours and 45 minutes after the last position entry), the patient's position was recorded as laying on the left side.


- Patient #13's record review on 10/17/2017 revealed admission to the 7N medical-surgical unit on 9/10/2017 and discharged on 9/29/2017 with a diagnosis of a right brain mass. The medical record lacked evidence staff followed an appropriate nursing care plan addressing potential skin integrity risks, initiated at admission, and updated it during the hospitalization to keep it current. The medical record revealed the patient did not have a pressure ulcer upon admission however, on 9/21/2017 a Stage 2 (partial thickness skin loss that is superficial and presents clinically as an abrasion, blister, or shallow crater) pressure ulcer was identified on the patient's left heel. On 9/23/2017, a pressure ulcer was identified on the patient's penile skin fold. On 9/27/2017, a pressure ulcer was identified on the patient's right buttock.

- Nursing Care Plan reviewed on 10/17/2017 at 3:00 PM revealed "Elevate Heels per Protocol" was marked as completed from 9/15/2017- 9/17/2017, on 9/21/2017, on 9/27/2017, and on 9/29/2017. The plan revealed nursing staff failed to document these protocol interventions from 9/18/2017- 9/20/2017, 9/22/2017 - 9/26/2017, and on 9/28/2017.

Clinical Informatics Staff M interviewed on 10/17/2018 at 3:45 PM confirmed the nursing staff failed to initiate a care plan that included skin integrity issues. Staff M indicated nursing staff should have been following pressure prevention protocols, which include turning the patient every 1-2 hours based on the assessments and Braden Scores.

Registered Nurse Staff O interviewed on 10/18/2017 at 1:11 PM indicated that a nursing care plan should be updated each shift and confirmed it should include actual patient problems and potential problems.

- Document titled "Wound and Skin: Pressure Ulcers Treatment and Prevention Protocol" reviewed on 10/18/2017 at 11:50 AM directed, reposition bed-bound (bed fast) patients at least every 1 ½ to 2 hours or more frequently based on the patient's tissue tolerance, level of activity/mobility, general medical condition, the overall treatment objectives, and assessments of the patient's skin condition...and...Braden Assessment score (a skin and risk assessment) of 18 are considered to be "at risk" for developing pressure ulcers, a score of 10-12 are at "high risk", and patients with a score of 9 or below are at a "very high risk".


- Patient #2's record review on 10/17/2017 revealed the patient was admitted to the medical-surgical unit on 10/9/2017 with a diagnosis of possible sepsis, and remains a current patient. Medical record review revealed this patient has an identified pressure ulcer to their left buttock fold and a colostomy (a surgically placed area on the stomach where a bag is attached to collect stool) with observed redness and small open areas around the stoma (exit point for stool from the stomach). Record review revealed patient #2 was ordered a turning schedule of every two hours by the wound and skin team, however the individualized nursing care plan lacked the intervention. Although the order is mentioned in one nursing shift assessment on 10/15/2017, review of the medical record lacked evidence patient #2 was turned every two hours as directed. The medical record revealed the individualized care plan included an intervention to elevate extremities, however the record lacked documentation the nursing staff elevated the extremities.

- Observations of Patient #2 on 10/16/2017 at 10:58 AM and 11:21 AM and on 10/17/2017 at 8:19 AM revealed the patient sitting upright in bed with the head of the bed elevated, both lower extremities, including heels, lying flat on the mattress, not in an elevated position.

Clinical Informatics RN Staff M interviewed on 10/17/2018 at 3:53 PM confirmed the nursing staff failed to initiate a care plan that included turning schedules, and comments, "they [nursing] should document what position they [the patient] are in every two hours."


Patient #3's medical record review on 10/16/2017 admission to the hospital on 10/8/2017 with a diagnosis of elevated troponin (blood marker for heart damage), elevated lactate (marker for severe infection) and seizure activity (uncontrollable, body-wide shaking). Patient #3 remains a current patient as of 10/17/2017. Medical record review revealed patient #3 had a history of seizure activity and had a physician's order for seizure precautions (steps such as reducing noise, dimming the lighting, and others to reduce the chance of the patient having a seizure), however, the medical record lacked evidence of nursing documentation related to seizure precautions, or care plan interventions related to seizure precautions.

Document titled "Seizure Precautions for Adults: Initiating and Maintaining" reviewed on 10/17/2017 directed, Update the patient's plan of care as appropriate, and document the following in the patient's medical record: date and time the seizure precautions were implemented, patient assessment findings regarding seizure risk, patient response to initiation of seizure precautions, any unexpected patient events or outcomes, interventions performed ...and patient/family member education.


Patient #4's record review on 10/17/2017 revealed admission to the hospital on 10/13/2017 with a diagnosis of cellulitis (skin infection) and end-stage renal disease (failure of the kidneys, requiring dialysis treatments) and remains a current patient as of 10/17/2017. Medical record review revealed patient #4 had several wounds to toes on bilateral feet. An order to elevate affected extremities on two pillows was placed on 10/13/2017, however, the medical record lacked evidence of nursing documentation related to elevating extremities, or care plan interventions related to elevating extremities.

Clinical Informatics Staff FF interview on 10/17/2017 confirmed the record lacked documentation and replies, "no, I do not see it."


- Patient #7's record review revealed an admission to the hospital on 9/2/2017 with a diagnosis of surgical wound infection and discharged on 9/8/2017. Medical record review revealed patient #7 had a surgical wound to her lumbar spine and pressure ulcers to her sacrum and left hip on admission. A physician ordered a turning schedule of every two hours, however, the individualized nursing care plan lacked the intervention.


Quality Staff CC interview on 10/17/2017 at 10:53 AM stated, "They [nursing staff] may not document on it because it is a standard of care. We always educate on documentation."

Based on observation, document review, and staff interview the hospital failed to ensure nursing staff (Staff B) followed accepted standards of practice for one of four observed medication administrations (Patient # 11). This deficient practice has the potential to cause patients to have adverse reactions to medications.

Findings include:

- Registered Nurse (RN), Staff B observed during a medication administration for Patient #11 on 10/16/2017 at 11:35 AM revealed them piercing the rubber septum of a 10-milliliter bottle of Sodium Chloride (a medication used to add fluid to the body) without cleaning the rubber septum. RN, Staff B administered 0.5 milligrams of Dilaudid (a pain medication) diluted with 9 milliliters of Sodium Chloride at an observed push rate of less than 10 seconds per 10 milliliters. This deficient practice could cause speed shock which is a sudden adverse physiological reaction to IV medications or drugs that are administered too quickly. Some signs of speed shock are a flushed face, headache, a tight feeling in the chest, irregular pulse, loss of consciousness, and cardiac arrest.

RN, Staff B interviewed on 10/16/2017 at 11:40 AM acknowledged they did not clean the rubber septum of the Sodium Chloride and stated, "I thought it was sterile because it had a cap on it". Staff B indicated she did not know how fast the medication was delivered, but thought it was supposed to be over 2-3 minutes.

- Medication Administration documentation for Patient #11 reviewed on 10/16/2017 directed that Dilaudid should be administered over two minutes.

- CDC (Centers for Disease Control and Prevention) guidance for safe medication injection practices, Proper hand hygiene should be performed before handling medications and the rubber septum should be disinfected with alcohol prior to piercing it.

- Policy review on 10/17/2017 revealed the facility failed to provide a policy directing staff to disinfect the rubber septum of a medication vial before piercing it.