HospitalInspections.org

The hospital reported a census of 262 patients with 26 records reviewed. Based on observation, medical record review, policy review and staff interview the hospital failed to ensure the nursing staff developed a plan of care for the use of restraints for 3 of 3 patients requiring the use of restraints (Patient #s' 3, 4 and 6).

Findings included:

- Observation of patient #3 on 3/8/10 at 10:38am revealed the patient was restrained with soft wrist restraints.

Review of the medical record lacked evidence of a plan of care for restraints.

Review of the hospital's Restraints for medical/surgical care of the patient, dated 4/28/09, directed staff to modify the patient's plan of care to reflect the use of restraints.

Administrative staff A on 3/10/10 at 1:30pm reported the hospital's computerized plan of care lacked the ability to address restraint use and acknowledged the medical record lacked a plan of care to meet this requirement.

- Observation of patient #4 on 3/8/10 at 11:30am revealed the patient was restrained with locked wrist restraints.

Review of the medical record lacked evidence of a plan of care for restraints.

Review of the hospital's Restraints for medical/surgical care of the patient, dated 4/28/09, directed staff to modify the patient's plan of care to reflect the use of restraints.

Administrative staff A on 3/10/10 at 1:30pm reported the hospital's computerized plan of care lacked the ability to address restraint use and acknowledged the medical record lacked a plan of care to meet this requirement.

- Observation of patient #6 on 3/10/10 at 11:30am revealed the patient had paralysis of their right arm and leg, which left their right limbs flaccid. Review of the medical record revealed the nursing staff placed the left wrist in soft wrist restraints on 3/8/10 at 11:00pm. The medical record lacked evidence of a plan of care for restraints.

Review of the hospital's Restraints for medical/surgical care of the patient, dated 4/28/09, directed staff to modify the patient's plan of care to reflect the use of restraints.

Administrative staff A on 3/10/10 at 1:30pm reported the hospital's computerized plan of care lacked the ability to address restraint use and acknowledged the medical record lacked a plan of care to meet this requirement.

The hospital reported a census of 262 patients with 26 records reviewed. Based on observation, medical record review, policy review and staff interview the hospital failed to ensure the nursing staff followed physician orders for 2 of 26 patients. (Patient #s' 5 and 7).

Findings included:

- Review of patient #7's medical record revealed they were admitted for treatment of cellulitis, status ulcers and wound infection. Review of the physician orders dated 3/5/10 revealed the following wound care orders:
1. Clean with Cetaphil cleaner.
2. Apply Nutra shield lotion to both legs.
3. Apply Santyl (a chemical debridement ointment) to wound bed.
4. Apply zinc to the peri-wound.
5. Apply Vaseline gauze to wound
6. Cover with 4X4 gauze and cling gauze.
7. Apply two layers of tubi-grips to both legs.

Observation of nursing staff I during patient #7's wound care treatment on 3/9/10 at 3:00pm revealed staff I donned gloves and cut the patient's old dressing with a pair of scissors from their pocket. Staff I removed the wound dressings. The dressings had a gross amount of yellow purulent drainage with a pungent odor covering 90% of the dressing.

Staff I rinsed the area with normal saline and padded the wounds dry with a 4X4 gauze, not the specified cleaner in the physician's order. Staff I measured the two legs wounds without changing their contaminated gloves. Staff I handled their digital camera with the same gloves.

Staff I continued to wear the same gloves for the patient's entire wound treatment and used the same contaminated scissors to cut the gauze.

Staff I on 3/9/10 at 3:00pm reported they obtained a wound culture at admission and reported the wound was positive for a staph aureus infection.

Administrative staff A on 3/9/10 at 4:45pm acknowledged that staff I should have changed their gloves between the dirty portion to the clean portion of the treatment.

- Review of patient #5's medical record revealed an admission date of 1/26/10 with a diagnosis of renal failure, which required dialysis treatments three times a week. Review of the patient's medical record revealed the dialysis nurses failed to follow the physician orders as follows:

1. Review of the treatment record dated 2/26/10 revealed the physician ordered 300 milliliters (ml) of normal saline if the patient's blood pressure drops below 90 systolic. Review of the treatment record revealed the patient's blood pressure drop to 66 systolic. The nursing staff documented they turned off the dialysis machine's ultrafiltration rate and failed to administer any normal saline.

2. Review of the treatment sheet dated 3/1/10 revealed the physician ordered 300 ml of normal saline if the patient's blood pressure drops below 90 systolic. Review of the treatment record revealed the patient's blood pressure drop to 88 systolic. The nursing staff documented they turned off the dialysis machine's ultrafiltration rate and failed to administer any normal saline.

3. Review of the treatment sheet dated 3/3/10 revealed the physician ordered 300 ml of normal saline if the patient's blood pressure drops below 90 systolic. Review of the treatment record revealed the patient's blood pressure drop to 69 systolic. The nursing staff documented they turned off the dialysis machine's ultrafiltration rate and failed to administer any normal saline.

Interview with licensed staff V on 3/9/10 acknowledged their staff failed to complete the nursing documentation and failed to follow specific orders for dialysis treatments.