HospitalInspections.org

Based on interview and record review, the facility failed to implement interventions as ordered by the provider to prevent a yeast infection from worsening for 1 (#4) of 10 sampled patients. Findings include:

During an interview on 12/14/21 at 11:45 a.m., NFI stated patient #4 had a yeast infection under the patient's breasts, abdominal folds and groin area that had worsened while the patient was in the hospital. NF1 stated patient #4 was a large person and it was very difficult for the patient to reach the areas where the infection was observed.

Review of patient #4's MAR, dated 9/30/21 through 10/27/21, showed the patient was to have Nystatin powder applied to the affected areas two times daily. The MAR showed 29 blank spots where nursing were to sign off that the medication had been administered. There were seven spots which showed the patient had refused the treatment. Out of 56 spots on the MAR, 29 showed the medication had not been administered.

During an interview on 12/15/21 at 2:30 p.m., staff member A stated when medication was administered there needs to be initials in the boxes that showed the medication had been given. Staff member A stated if the patient refused the nursing staff were to initial it and draw a circle around their initials in red pen. Staff member A stated the unit managers were to audit the MARs for errors. Staff member A stated a blank spot on the MAR was treated as a medication error.

During an interview on 12/15/21 at 3:50 p.m., staff member E stated she had training on abuse/neglect in June, 2021. Staff member E stated there is abuse/neglect information, in a packet, when she was hired. Staff member E stated she had not witnessed any abuse/neglect in the facility. Staff member E stated if abuse/neglect was witnessed she would report to the floor nurse and if that did not have results, then go to the manager, ADON and/or the DON.

During an interview, on 12/15/21 at 4:00 p.m., staff member D stated he had been working at the facility since May 26, 2021. Staff member D stated he had received a handout on abuse/neglect, and had abuse/neglect training prior to starting work at the facility. Staff member D stated patient #4 was to be assessed and had Nystatin powder applied to her abdominal folds, groin area, and under the breasts two times a day. Staff member D stated patient #4 should have been reassessed after the 13 days and if it was healed then continue to assess skin. Staff member D stated if the infection was not healed he would contact the provider. Staff member D stated blank spots on the MAR either were overlooked or the medication had not been given. Staff member D stated it would be turned in as a medication error. Staff member D stated when a patient refused medications or treatments, the nurse initials it and draws a red circle around the initials. Staff member D stated there should be a progress note and documentation on the back of the MAR for any refusals.

Review of the Physician's Order Sheet, dated 9/16/21, showed patient #4 was to have Nystatin powder applied to under the breasts, groin, and and pannus two times daily for three weeks for candidiasis.

Review of the Physician's Order Sheet, dated 10/9/21, showed patient #4 was to have Nystatin powder applied to the affected area two times daily for three weeks for fungal dermatitis.

Review of the History and Physical, dated 9/16/21, showed patient #4 had an excoriated rash under breasts, abdominal fold and groin area. Currently using Nystatin powder.

The facility failed to apply Nystatin powder to the affected areas for patient #4 which made the infection worse upon discharge.

Review of the facility policy, Medication Administration & Safe Handling effective 11/22/21, showed, under documentation:
-"...document on the MAR immediately after the administration of each patient's medication
-document on the MAR refusals, PRN's and response, STAT medications..."

Review of the facility's policy, titled Allegations of Abuse and Neglect, showed the following:

-Medical Neglect: failure to provide care for existing medical problems. Examples include: Not taking action on medical problems, prescribed treatment, or therapies; not calling a physician when necessary; failure to monitor for adverse drug reactions.

Review of the facility Abuse Investigation-Final Summary, dated 11/18/21, showed an allegation of abuse/neglect regarding patient #4. The form showed the following investigation:
-"...Upon patient discharge on 11/2/21, it was noted by patient's group home her yeast infection had worsened
-Upon admission, [patient's name] skin condition was identified and orders were written
-The patient did refuse some treatments throughout her admission, but overall treatment was not administered routinely as ordered. Ultimately this could have contributed to exacerbating her condition
-The finding of the investigation does meet the definition of neglect
-"The corrective action taken was coaching on required documentation and oversight..."