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Based on observation, staff interview, record and policy review, the facility failed to ensure organized nursing services met the needs of the patients when:

1. Staff did not follow hospital policy and accepted nursing standards of practice when verifying NG tube (Nasal Gastric- tube from the nose into the stomach) placement and there was no NG placement policy and procedure to ensure the evaluation of staff competencies in the proper verification of nasal gastric or feeding tube placement. This failure resulted in one of eight patients with NG tubes (Patient 30) having the feeding tube placed in the lung causing severe respiratory distress. (Cross Reference A 395)

2. One of 30 patients (Patient 15) lacked a nutrition plan of care and assessment of a Stage three pressure ulcer (full thickness tissue loss) by the dietitian resulting in potential for inadequate treatment for wound healing. (Cross Reference A 396)

3. One of 30 patients (Patient 10) lacked a skin integrity or pressure ulcer prevention care plan, according to the facility's policy for implementation, when the patient was at high risk for skin breakdown. (Cross Reference A 396)

4. One of 30 patients (Patient 30), had a deep tissue injury (injury to tissue below the skin's surface, caused by excessive unrelieved pressure to an area) on her coccyx/sacrum and did not receive a timely consultation by the wound nurse and did not have her care plan updated to reflect or address the issues licensed staff had in providing care designed to help minimize further skin breakdown. The wound progressed to an unstageable pressure ulcer (full thickness tissue loss in which actual depth of the ulcer is obscured). (Cross Reference A 396)

5. Nursing Staff did not verify orders for chest tube and NG tube placement for one of eight patients (Patient 30) resulting in treatment provided without an order. (Cross Reference A 395)

6. Two staff did not administer medication to two of eight patients (Patients 4 and 30) according to doctors' orders and orders were not clarified before the medication was given, which could lead to administration of medication through the wrong route or medication given that was inappropriate for that route. (Cross Reference A 405).

The cumulative effect of these systemic problems resulted in the inability of the facility to provide an organized 24-hour nursing service, which met the needs of the patients, when care was not provided in accordance with physician orders and acceptable nursing standards of practice.

Based on interview and record review, the facility failed to ensure the nursing care of one of eight patients (Patient 30) was in accordance with accepted standards of nursing practice and hospital policy when:

1) Licensed staff did not verify the placement of a nasogastric tube correctly or by hospital practice (a nasogastric tube, or NGT, is a tube placed through the nose, down the throat, and into the stomach to administer medication/tube feeding or to suction out stomach contents).

2) Licensed staff did not obtain a physician's order to reinsert a nasogastric tube on multiple occasions and;

3) Licensed staff did not verify orders for two chest tubes (tube that is inserted through the chest wall into the lung to remove air or fluid).

These failures resulted in harm when Patient 30 had a nasogastric tube placed into her lung which caused serious lung injury and severe respiratory distress, and necessitated the placement of two chest tubes and mechanical ventilation (use of a machine to replace or support breathing). Patient 30 was subsequently given oral medication into her lung tissue, instead of her stomach. In addition, Patient 30 faced potential harm when licensed staff failed to obtain necessary physician orders for multiple NGT reinsertions and for chest tube settings.

Findings:

1) During an interview on 8/29/14 at 11:50 a.m., Administrative Licensed Staff K (Adm. Staff K) stated on 8/20/14, Licensed Staff C attempted to place an NGT into Resident 30's stomach. Adm. Staff K stated the NGT ended up in Patient 30's right lung, not in her stomach. Adm Staff K stated Licensed Staff C had tried to check correct placement of the NGT by attempting to aspirate stomach contents (withdraw stomach/gastric contents via syringe) and auscultation of injected air (listening to air injected into the stomach through stethoscope placed over the abdomen). Adm. Staff K stated when Licensed Staff C pulled back on the syringe in an attempt to aspirate stomach contents, Licensed Staff C noted serosanguineous fluid (containing blood and serum). (According to Lippincott Manual of Nursing Practice, Ninth Edition, dated 2010, stomach fluid characteristics are grassy green, clear and colorless, or brown). Adm. Staff K stated when Licensed Staff C listened as she injected air into the tube (a technique used to verify NGT is in the stomach and not the lung), Licensed Staff C was unable to hear the air. Adm. Staff K reported Licensed Staff C made three attempts to hear air, but was unable to hear the injected air on all three attempts. Adm. Staff K reported Licensed Staff C told Adm. Staff K her "gut told her" she was not comfortable with the NGT placement. Adm. Staff K stated Licensed Staff C had asked another licensed nurse (Licensed Staff D) to double check the NGT's placement. Licensed Staff D told Licensed Staff C she did not hear injected air while listening over the stomach but because they had the (serosanginous fluid) residual (the amount of liquid that remains in the stomach after tube feeding) they thought the NGT was probably in the stomach. Adm. Staff K stated Licensed Staff C called Resident 30's physician (Physician E) after midnight and he ordered a chest x-ray for the morning.

During an interview on 8/29/14 at 12:11 p.m., Administrative Licensed Staff A (Adm. Staff A) stated licensed staff verified an NGT was properly placed into the stomach (instead of misplaced into the lung) by checking for air bolus (listening to injected air) and aspirating gastric residual (withdrawing stomach contents). She stated a second licensed nurse would then confirm placement. When queried (questioned) what nurses should do if they aspirated residual but did not hear the injected air, she stated they should call the physician and ask for a chest x-ray to verify placement. When further queried why the chest x-ray was not obtained until the morning (approximately 4 hours after the NGT was placed), she stated it probably should have been done quicker.

During an interview on 8/29/14 at 12:11 p.m., Adm. Staff K stated the facility did not have a policy and procedure for licensed nurses to follow when verifying placement of an NGT. She stated the nurses follow the process outlined in a nursing textbook by Lippincott (Lippincott Manual of Nursing Practice, Ninth Edition," (dated 2010).

During a telephone interview on 8/29/14 at 1:03 p.m., Physician E stated Patient 30 had multiple medical problems requiring her to be placed in the intensive care unit prior to the NGT being misplaced into her lung. He said Patient 30 had a weak gag reflex (coughing in response to something going down the throat). He stated licensed staff verified NGT placement by checking for gastric residual and listening for air injected into stomach. He said if a nurse was in doubt regarding proper placement, he/she should call the physician and obtain an order for chest x-ray verification. He reported Patient 30's nurse called him in the early morning hours of 8/20/14 and notified him the patient was short of breath (which she had a history of experiencing). He said the nurse did not notify him there was a question regarding proper NGT placement. Physician E stated he ordered the nurse to give medication (Lasix - a medication used to remove fluid) for the shortness of breath and to then check a chest x-ray in the morning. He reported that he ordered the morning chest x-ray to evaluate Patient 30's lung status and shortness of breath, not to verify NGT placement.

Review of facility document titled, "Lippincott Manual of Nursing Practice, Ninth Edition," (dated 2010) indicated staff should consider x-ray confirmation of tube placement in patients with risk factors for malpositioning. The document indicated a reduced cough or gag reflex was a risk factor for NGT malpositioning.

Review of Patient 30's Critical Care physician note, dated 8/20/14 at 7:45 a.m., indicated Patient 30 was in the intensive care unit (ICU) in stable condition the previous night (8/20/14). The document revealed early in the morning of 8/21/14, Physician E ordered intravenous Lasix to be given to Patient 30 for shortness of breath. The patient's shortness of breath improved after administration of the Lasix. The document indicated at 4 or 5 in the morning, her respiratory status got worse. A chest x-ray was done which revealed the NGT was in her right lung and the right lung now had a pneumothorax (abnormal collection of air or gas in the pleural space which impairs breathing). The document indicated the NGT was removed and Patient 30's condition deteriorated around 6 a.m. A repeat, stat (immediate) chest x-ray revealed a large right tension pneumothorax (complete collapse of the lung and a medical emergency) and her oxygen level was low at 70 % - 80% (normal is 95-100%) despite being on high-flow oxygen. A chest tube was then placed emergently and she was placed on a mechanical ventilator.

Review of Patient 30's ED Physician Note, dated 8/20/14, indicated Physician P was called to assess a rapidly deteriorating patient in the ICU at approximately 6:30 a.m. The physician note revealed an NGT had been placed a few hours ago in the right bronchus (lung) and then removed. The document further revealed the patient had a tension pneumothorax on bedside X-ray. The note indicated Physician P performed needle decompression (to allow the lung to re-expand) and placed a chest tube (thoracostomy) while Physician E helped with resuscitation (emergency procedures to stabilize patient).

Review of a Physician note, dated 8/21/14, indicated Patient 30 had a second chest tube placed to further stabilize her condition.

During a telephone interview on 9/3/14 at 4:10 p.m., Licensed Staff D stated she worked as a resource nurse on 8/20/14. She reported Licensed Staff C had placed an NGT into Patient 30 and asked her to verify the tube's correct placement. Licensed Staff D stated first Licensed Staff C checked placement by listening for injected air and attempting to withdraw gastric contents. She stated Licensed Staff C withdrew fluid that was pink in color. Licensed Staff D stated she then attempted to verify placement. She reported she was unable to hear any injected air and when she attempted to withdraw gastric contents, she saw pink, brown/yellow/greenish fluid. She further stated neither of them were able to hear the air they injected, so she suggested Licensed Staff C call Physician E and notify him. She stated she went home sick around 00:30 a.m. When queried how she usually checked placement of an NGT, she stated she obtained a chest x-ray order. When queried if she checks the withdrawn fluid's pH (acid/base level) to determine if it is actually gastric fluid from the stomach, she stated she had not seen licensed staff check gastric pH and the facility did not have supplies available to readily do so.

During a telephone interview on 9/4/14 at 2:26 p.m., Licensed Staff C stated she took care of Patient 30 on the evening of 8/19/14 until the morning of 8/20/14. She stated in the past, Patient 30 had developed respiratory distress easily and became fluid overloaded. She reported around midnight on 8/20/14, Patient 30 had pulled out her NGT and appeared to be fluid overloaded (fluid accumulation in the lung). Licensed Staff C stated she notified Physician E via telephone about the NGT and shortness of breath. She stated the physician ordered to hold the tube feeding, give Lasix and a get a chest x-ray in the morning. Licensed Staff C reported after she spoke to Physician E, she then attempted to reinsert the NGT. She stated Licensed Staff D assisted her in the process. She stated as she advanced the NGT, pink fluid entered the tube. Licensed Staff C stated she and Licensed Staff D both tried three times to listen for injected air but they could not hear anything. She stated she did not feel good about the NGT placement and her gut said it was not there and stated she clamped the NGT. Licensed Staff D stated she did not notify Physician E she had seen pink fluid in the NGT or that she thought the tube might be misplaced. When queried if she thought the pink fluid was gastric fluid, she responded she didn't think of that. When queried if she checked the pink fluid's pH to assess if it was indeed stomach contents, she responded, "no." Licensed Staff C stated she later gave a pain pill (Percocet) through the NGT and flushed the medicine through the tube with "about" 30 cc of water.

During this same interview, Licensed Staff C stated Patient 30 had a chest x-ray at about 4:40 a.m. on 8/20/14. She stated at approximately 5:40 a.m. (over five hours after the NGT was inserted) she received a call from radiology staff who told her the NGT was in the right lung. She stated she then pulled the NGT out and notified the charge nurse. Licensed Staff C stated after she pulled the NGT out, she notified Physician E and stated he instructed her to watch the patient and he would be there in ten minutes (he was not in the hospital). Licensed Staff C stated at approximately 6:00 a.m., Patient 30 developed increased respiratory distress and her oxygen level dropped. Licensed Staff C stated she again called Physician E who ordered a stat chest x-ray. She stated Licensed Staff R telephoned the emergency department to request assistance and Physician P came to the bedside, performed needle decompression and then inserted a chest tube. She said Physician E arrived and intubated the patient (placed her on mechanical ventilation).

During an interview on 10/9/14 at 1:30 p.m., Adm. Staff K stated licensed staff did not usually check pH of aspirated fluid to verify NGT placement.

Review of facility document titled, "Provision of Resource Manuals on Skills and Nursing Practice" (revised 3/12) indicated Lippincott Manual of Nursing Practice, 8th Edition, was to be used as the resource for obtaining information regarding the practice of basic nursing skills not included in the facility's standards.

Review of facility document titled, "Lippincott Manual of Nursing Practice, Ninth Edition" (dated 2010) indicated staff should check whether an NGT was in the stomach by first: a) asking the patient to talk, b) checking the mouth with a penlight, c) attaching a syringe to the end of the NGT and placing a stethoscope over the abdomen and injecting air while listening to the abdomen (air can be detected as a "whooshing" sound as it enters the stomach but not if it enters the lungs), d) obtaining aspirate with a syringe - if aspirate was obtained, check for gastric placement indicators: pH less than or equal to 5 and gastric fluid characteristics of grassy green, clear and colorless or brown, e) consider x-ray confirmation of tube placement in patients with risk factors for malpositioning of tube such as reduced cough and gag reflexes.

Review of an online publication of American Association of Critical Care Nurses (revised 12/2009) indicated blind placement of a feeding tube could cause serious and even fatal complications. The document further indicated that listening to injected air was not reliable in distinguishing between respiratory and gastric placement. The document indicated that checking aspirate appearance and pH were not sufficiently accurate to eliminate the need for a confirmatory x-ray prior to first-time use of a feeding tube. The document also revealed a properly obtained and interpreted radiograph was recommended to confirm correct placement of any blindly inserted tube before its initial use for feedings or medication administration.

Review of four licensed nursing personnel files on 10/8/14 indicated that there were no competency evaluations for NGT placement and medication administration.

During an interview on 10/8/14 at 3:05 p.m., Adm. Licensed Staff A stated the facility did not conduct annual NGT placement or NGT medication administration training to licensed staff.

During an interview and concurrent document review on 10/9/14 at 1:30 p.m., Administrative Staff T stated the facility did not have a policy or procedure for NGT medication administration. She further stated they used the nasogastric tube feeding instructions outlined in the resource textbook "Medical-Surgical Nursing: Preparation for Practice" (dated 2010). The instructions did not indicate how to crush pills, administer liquid medications, or how to flush the tube between and after medication administration.

2) Review of Patient 30's medical record Gastrointestinal Tube Insertion/Management, dated 8/4/14 indicated Physician S ordered an oral gastric tube be placed and set to low, intermittent suction. No other feeding tube orders were located in Patient 30's medical record.

Review of Patient 30's medical record nursing notes, dated 8/15/14 through 8/20/14, revealed Patient 30 had self-removed her NGT on multiple occasions. During this same timeframe, the nurses notes indicated licensed staff had reinserted Patient 30's NGT on 8/16/14 at 12:24 a.m., on 8/18/14 at 3:30 a.m. and 6:55 a.m., on 8/19/14 at 4:00 p.m., and on 8/20/14 at 12:30 a.m. No physician orders to re-insert the NGT were located in Patient 30's medical record.

During an interview on 10/9/14 at 8:15 a.m., Adm. Staff K confirmed that Patient 30's medical record did not contain physician orders to re-insert nasal gastric tubes (or NGT's) on the above five occasions.

During an interview on 10/6/14 at, Licensed Staff H stated that if a patient needed an NGT placed, first check to see that you had a doctor's order.

3) Review of Patient 30's medical record physician notes indicated Patient 30 had two chest tubes placed on 8/20/14; the first was documented as placed at 6:40 a.m. and the second was placed at 5:15 p.m. No physician order clarifying location and chest tube suction level was located in the medical record. A physician order to increase suction on the chest tubes to 30 cm was entered on 8/21/14 at 5:38 a.m. (almost 24 hours after the first chest tube was placed).

Review of Patient 30's nursing notes, Tubes and Drains, indicated Licensed Staff C, D, F, and G, documented the chest tubes were connected to 20 cm of wall suction from 8/20/14 at 7:00 a.m. until 8/21/14 at 8:00 a.m.

During an interview on 10/9/14 at 8:15 a.m., Adm. Staff K stated no physician orders for either of Patient 30's chest tubes were in her chart until 8/21/14 at 5:38 a.m.

Review of facility procedure protocol titled, "Management of Patient with Chest Tubes" (dated reviewed 4/14) indicated licensed staff would apply the prescribed (ordered) amount of suction.

Based on observation, staff interview, and record review, the facility failed to ensure a plan of care for three patients (Patient 10, 15 and 30) out of 30 patient records, was developed, followed, and kept current when:

1. Patient 15's closed record revealed there was no nutritional plan of care, nutritional assessment or treatment plan for a stage three (full thickness skin loss) pressure ulcer and diagnosis of diabetes (inability to regulate blood sugars). This failure could lead to poor wound healing due to lack of nutritional support.

2. One Patient, (Patient 10) who was assessed as having skin breakdown risk, fractured hip, recent surgery and mobility problems, did not have a a skin integrity or pressure sore prevention care plan. This failure increased the patient's risk for skin breakdown when a plan of care was not developed.

3. One patient (Patient 30), who had a deep tissue injury (injury to tissue below the skin's surface, caused by excessive pressure to an area) of the coccyx/sacrum (area located on the low back, just above the buttocks), did not receive a timely consultation by the wound nurse and did not have her care plan updated to reflect or address issues licensed staff had providing care designed to help minimize further skin breakdown, resulting in full thickness skin loss.

Findings:

1. On 10/8/14, review of Patient 15's closed medical emergency room record, indicated on 7/13/14, Patient 30 had a history of Type Two Diabetes, had fever and chills for 24 hours and was diagnosed with sepsis (the body's severe response to bacterial infection). Laboratory results included Glucose (blood sugar) level of 295 milligrams/deciliter (mg/dl) high (normal-74-106), Albumin (protein level in blood) was 2.1 gram (Gm)/dl -low (3.4-5.0-normal). Review of the Braden scale (skin assessment tool to identify risk for skin breakdown) located in the 7/14/14 nursing notes, indicated the patient was bedfast (unable to get out of bed), mobility was limited and nutrition was inadequate. Patient 15's Braden score was 13 (moderate risk) for the development of skin breakdown. Nurses notes from 7/13/14 indicated that there was excoriation (skin breakdown or an abrasion) to the coccyx area and on 7/14/14, indicated there was redness on left lower leg, blanchable redness (redness fades when touched and released) to the patient's "bottom" and abrasion on her left buttock. Nursing notes from 7/16/14 indicated that Patient 15 had a stage three pressure ulcer, which started as an abrasion. The wound care nurse's notes dated 7/16/14, indicated that the patient was assessed as having a stage three pressure ulcer to the left buttock. The notes indicated that the area was previously assessed with abrasion/erosion, however no evidence of pressure ulcer was present at that time (7/14).

On 10/8/14, review of the nutrition notes for 7/14/14, did not address skin breakdown nor the patient's diabetes and the diet that was recommended was a carbohydrate controlled diet. Another nutrition note written on 7/18/14 indicated the patient had inadequate oral intake and documented a carbohydrate controlled diet and added health shakes three times a day with meals. The notes did not mention diabetes, pressure sore nor skin breakdown. The Glycemic Management (Diabetes) flow sheet for 7/13/14-7/18/14 indicated that finger sticks for blood testing were done, and insulin (lispro- blood sugar lowering medication) or oral blood sugar medication (glipizide) was given. The flow sheet indicated blood sugar ranges were between 87-333. mg/dl.

On 10/8/14 review of the Interdisciplinary plans of care for Patient 15, indicated care plans for fall prevention, self care deficit, pressure ulcer prevention, infection/isolation, pain management, blood clot prevention and activity intolerance with impaired mobility but did not include a nutrition care plan which addressed skin breakdown or diabetes.

During an interview on 10/8/14 at 11:00 a.m., Dietitian I stated, while reviewing Patient 15's record, that she saw the patient on 7/14/14. Dietitian I stated she did not see anything in her notes about Patient 15 having a pressure sore. Dietitian I stated she would have increased Patient 15's protein as her needs would have been greater with a pressure sore. Dietitian I stated her notes indicated she did a second assessment on 7/18/14 and she added supplements because the patient was not eating well. Dietitian I stated she did not see medical supplements such as Vitamin C and Zinc in the physicians order, and she would have suggested them for wound healing if she knew about the pressure sore. The Dietitian also stated the diet ordered was for a heart healthy diet, low cholesterol, and no added salt, and stated since Patient 15 was diabetic, a diabetic low carbohydrate diet should have been ordered. Dietitian I stated she did not see the pressure ulcer documentation in the nurses notes or the pressure ulcer care plan. Dietitian I stated if she knew about the patient's pressure sore she would have suggested 1.2-1.4 gm protein/ kilogram (kg) or followed the facility policy recommended guidelines instead of the 1.0-1.2 gm protein/kg she calculated for Patient 15's protein needs. Dietitian I stated she would have recommended vitamins to the physician. Dietitian I agreed that there should have been a nutritional care plan due to diabetes.

On 10/8/14, review of the Facility Guidelines for Nutritional Requirements, revised 6/14, for estimating protein requirements, indicated "normal" protein needs were .8-1.0 gm/kg body weight and 1.2-1.5 gm/kg body weight for (mild to moderate stress) and 1.5-2.0 gm/kg for moderate to severe stress.

On 10/8/14, review of the Pressure Ulcer Prevention policy, effective 6/2012, indicated that factors contributing to the risk of skin breakdown included low albumin and diabetes.

On 10/8/14, review of Nutrition Screening, Assessing and Reassessing for Acute Care policy, revised 6/14, revealed that indicators such as stage three pressure ulcer, low albumin and uncontrolled diabetes increased severity and need for the dietitians consultation. The policy indicated that the dietitian may upgrade or down grade the patient's level of care depending on information obtained from clinical staff, patient chart or from the family. The policy directed the dietitian gathered data from the patient's medical record, patient and family interviews and input from other members of the healthcare team to make assessments. The data was evaluated to determine the patient's nutrition status and develop an appropriate plan of care for nutrition interventions. The nutrition care plan should be documented in the electronic health record.

On 10/9/14, review of the Use of the Interdisciplinary Plan of Care (IPOC) policy, revised 11/12, indicated that the IPOC was a interdisciplinary tool used in combination with the patient's health record to facilitate communication among the healthcare team and was used to document patient problems identified by nursing and other healthcare professionals. The identified problems drive the process to establish outcome goals and individualize planned interventions. The IPOC should be reviewed and revised by members of the team.

2. On 10/8/14, review of Patient 10's medical record indicated Patient 10 was admitted on 10/6/14 with a right hip fracture. The nurse's notes, dated 10/7/14, included a Braden score of 15 (assessment tool for skin breakdown). The Braden assessment indicated Patient 10 was bedfast, mobility was limited and friction and shear (skin and adjacent body surface rub against each other causing skin breakdown) was a potential problem. There was a care plan initiated for pain, fall prevention and blood clot prevention but there was no care plan for prevention of skin breakdown. The Braden electronic assessment form indicated Patient 10 was at risk for skin breakdown when the skin integrity score was less than or equal to 18 and to initiate a patient problem on the IPOC (Interdisciplinary Care plan). Review of nurses electronic notes indicated on 10/7/14 at 7:45 p.m., the skin was not intact. On 10/8/14, Nurses electronic record indicated the skin was not intact and there was a surgical incision. Braden score was 16.

During an interview on 10/8/14 at 9 a.m., Clinical Practice Manager J stated, while reviewing Patient 10's electronic medical record, with a Braden score of less than 18 or if there was a wound problem identified, staff should do a pressure prevention care plan. Clinical Practice Manager J stated Patient 10 should have had a care plan with a Braden score of 15 and also because it was noted Patient 10 had hip surgery the day before.

During an interview on 10/8/14 at 9:10 a.m., Licensed Staff L stated she took care of Patient 10 that day and stated nurses documented the skin integrity and utilized the Braden score for skin assessment. Licensed Staff L stated a score of 15 -18 was a risk for skin breakdown and a care plan should have been done. Licensed Staff L stated usually nursing staff completed a care plan check every shift. Licensed Staff L agreed skin breakdown prevention or pressure ulcer prevention should have been initiated for this patient.

During an observation and interview on 10/9/14 at 8:50 a..m., Non Licensed Staff Q turned Patient 10 to the side to clean her and helped the nurse lift Patient 10's heels to inspect for skin breakdown. Non licensed staff Q stated he turned the patient every two hours to prevent skin breakdown and it was important for staff to do this and it should be part of their plan of care.

On 10/9/14, review of the Pressure Ulcer Prevention policy, dated 6/2012, indicated the Braden scale was used to assess the risk of developing a pressure ulcer. The Policy indicated for a patient greater than five years of age, if the Braden score was 18 or less, the patient was determined to be at risk for developing a pressure ulcer/skin breakdown. The Policy indicated to initiate the pressure ulcer prevention and management interdisciplinary plan of care(IPOC) for any patient at risk for obtaining a pressure ulcer and to individualize the patient interventions in the plan of care for each patient.



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3. Review of Patient 30's medical record revealed two photographs taken on 8/8/14 of Patient 30's coccyx/sacral area. These two photos revealed a circle-shaped wound that measured approximately 7 X 6 centimeters (cm). The photo indicated the wound was dark purple/black in color. A tape measure appeared in the photo and was dated 8/8/14; the tape measure indicated the wound was on the patient's coccyx.

Review of Patient 30's medical record nursing notes dated 8/5/14 (the day after admission to the hospital) revealed her skin was intact with no pressure ulcers (bed sores) or deep tissue injury. The record revealed she had a Braden Score of 11 (indicating high risk for developing pressure ulcers).

During an interview and concurrent medical record review on 10/9/14 at 3:15 p.m., Administrative Licensed Staff K stated the facility requested a consult with the wound nurse specialist (Wound Care Staff M) on 8/8/14, the day the photos were taken. She stated Wound Care Staff M was unable to assess the patient that day so Licensed Nurse N assessed the patient. (She stated Licensed Nurse N had been trained to assess wounds but was not a wound care nurse specialist). Review of Patient 30's medical record indicated Licensed Staff N diagnosed Patient 30's wound as a deep tissue injury (injury to tissue below the skin's surface, caused by excessive pressure to an area).

During a telephone interview and concurrent electronic medical record review on 10/9/14 at 4:00 p.m., Wound Care Staff M stated the photograph of Patient 30's coccyx/sacral wound dated 8/8/14 looked like a deep tissue injury. She stated she usually got called to see patients with deep tissue injuries. She stated she covered two facilities and was not always available to assess patients right away. Wound Care Staff M stated Licensed Staff N was trained to assess wounds and assessed Patient 30 on 8/8/14. Licensed Staff N documented the wound was a deep tissue injury. Wound Care Staff M stated she came to the hospital to assess Patient 30 on 8/18/14 (ten days after the original wound consult referral) but the patient was too ill to be seen. She stated she returned four days later on 8/22/14 (14 days after the original wound referral) and assessed Patient 30. She stated the coccyx/sacral wound had evolved and had become unstageable (full thickness tissue loss in which actual depth of the ulcer is obscured).

During an interview and concurrent medical record review on 10/9/14 at 4:00 p.m., Administrative Licensed Staff K confirmed that no nurses with wound training had assessed Patient 30's wound during the 10 day period between 8/8/14 and 8/18/14. When queried (questioned) when a patient with a deep tissue injury should be reassessed by a wound specialist, Wound Care Staff M stated it was her standard of practice to reevaluate a deep tissue injury within seven days.

Review of Patient 30's Integumentary (skin) Notes from 8/16/14 through 8/22/14 (the day wound nurse assessed the patient), licensed nurses documented the location, color, drainage and dressing type for Patient 30's coccyx/sacral wound. There was no documentation of any measurements of the wound's size, which would monitor if the wound was progressing in size.

Review of Patient 30's wound document note dated 8/22/14, indicated Wound Care Staff M assessed Patient 30 on 8/22/14, 14 days after the wound care consultation request. The document indicated Wound Care Staff M determined Patient 30's coccyx/sacral wound had increased in size to 8 cm X 8 cm and had progressed to an unstageable pressure ulcer. The document indicated the wound had eschar (dry scab formed on the skin) and the surrounding tissue had partial thickness opening on the skin.

Review of Patient 30's medical record physician progress note revealed Physician O assessed Patient 30 two weeks later on 9/5/14. Physician O documented the coccyx/sacral wound had further progressed so the surrounding tissue had full-thickness skin loss extending approximately 1 to 2 cm beyond the eschar.

Review of facility policy titled, "Pressure Ulcer Treatment" (effective date 6/2012) indicated staff entered a referral to the, "Center for Wound Care" for patients with suspected deep tissue injury. The facility document did not include the frequency or type of wound monitoring expected from licensed staff.

Review of online document titled, "Prevention and Treatment of Pressure Ulcers: quick Reference guide" (dated 2014 by National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance) indicated suspected deep tissue injury should be re-assessed at least weekly to evaluate progress toward healing, detect complications as early as possible, and adjust the treatment plan accordingly. The document indicated the physical assessments should include the size of the wound.

During an interview and concurrent medical record review on 10/9/14 3:15 p.m., Administrative Licensed Staff K stated Patient 30's family had refused to allow facility staff to turn and reposition the patient at times. She stated one of Patient 30's physicians had spoken to the family about the need to reposition the patient in order to prevent further skin breakdown. When queried if licensed staff had documented the family's resistance to repositioning the patient or developed a plan a care to address the issue, she stated they had not.

Review of Patient 30's nursing notes for activities of daily living (from 8/19/14 through 8/21/14) indicated staff repositioned Patient 30 every two hours. The nursing notes did not indicate family resisted having the patient repositioned. Review of Patient 30's care plans indicated staff addressed pressure ulcer prevention and management including strategies to address skin assessment, turning, relieving duration and intensity over bony prominence's, and wound care management, and patient and family education. The care plans did not include a plan to address the families alleged resistance to having Patient 30 repositioned. The plan of care did not have specific assessment instructions of how nurses were to assess the wound such as measuring or how often a wound care specialist should assess and monitor the wound to determine appropriate treatment.

Review of a physician's note dated 9/5/14 indicated that during a significant part of her hospitalization, Patient 30 was rather immobile due to her profound medical condition (the record indicated she had been on a special bed to help prevent pressure ulcers).

Review of Patient 30's care plans indicated her plans of care were not individualized to address repositioning needs in light of her profound medical condition.

Review of facility policy titled, "Pressure Ulcer Prevention" (dated 6/2012) indicated staff should modify and individualize interventions in the plan of care as needed or as appropriate.

Review of online document titled, "Prevention and Treatment of Pressure Ulcers: quick Reference guide" (dated 2014 by National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance) indicated regular positioning is not possible for some patients because of their medical condition, and an alternative prevention strategy may need to be considered.

Based on observation, interview, and record review, the facility failed to ensure two of eight patients (Patient 4 and Patient 30), received medication as ordered by the physician.

Findings:

During an observation on 10/6/14 at 3:50 p.m., there was a large male patient (Patient 4) intubated (tube placed into lungs for breathing) with a nasal gastric tube in the Intensive Care Unit.

Review of Patient 4's electronic record on 10/7/14, indicated on 10/07/14 at 6:39 a.m., prednisone 10 mg (anti-inflammatory drug) was ordered by the physician and the route of administration was PO (by mouth). There was also an order for Acetaminophen - Hydrocodone (Norco 10 Mg oral tablet- narcotic pain medication and Tylenol) ordered on 9/29/14 PO for pain.

During an interview on 10/7/14 at 11:25 a.m., Administrative Licensed Staff A stated that the Nurse (Licensed Staff B) taking care of Patient 4, should have clarified with the doctor if he wanted the patient to have the the medication PO or by nasal gastric tube. Administrative Licensed Staff A stated that Patient 4 was intubated since he came in and had surgery on 9/29/14.

During an observation on 10/7/14 at 1:30 p.m., Patient 4 was still intubated and had an NG tube, and had several surgical drains from his abdomen and a colostomy (opening in the large intestine) bag.

During an interview on 10/7/14 at 2 p.m., Licensed staff B stated she had the order changed from PO to NG (nasal gastric) because the patient was intubated. Licensed Staff B stated she gave the prednisone before calling the doctor and crushed it and gave it through the NG tube. Licensed Staff B agreed she should have obtained the order change first, before giving the medication a different way than was ordered.

Review of the "Medication Details" electronic record for Patient 4 indicated on 10/7/14 that prednisone 10 mg was given by the nurse at 8:36 a.m., by NG tube and that the order was then modified by the nurse at 11:11 a.m., on 10/7/14 and verified with the physician. The order for acetaminophen- Hydrocodone (Norco 10 mg-325 mg) oral tablet was also changed from PO route to NG route.

Review of the "Medication Administration" policy, last revised 8/14, indicated any questions about orders for drugs or biologicals were expected to be resolved prior to the preparation, or dispensing or administration of the medication or biological. The "Medication Errors" policy, revised 2/13, indicated a definition of a medication error included dispensing or administration of a medication by an incorrect route.


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Review of Patient 30's medical record revealed Patient 30 had a physician order to receive one Percocet tablet (a narcotic pain medication) by mouth for pain. The record further revealed Licensed Staff C gave Patient 30 one Percocet tablet by mouth on 8/20/14 at 12:53 a.m.

During a telephone interview on 9/4/14 at 2:26 p.m., Licensed Staff C stated she gave Patient 30 the Percocet tablet on 8/20/14 at 12:53 a.m. through her nasogastric tube (a tube inserted through the nose extending into the stomach), not by mouth. She stated she flushed the medication through the tube with "about" 30 cc of water (approximately 1 ounce).

Review of facility policy titled, Administrative Manual (revised 8/14), indicated healthcare providers should perform at least, "two checks" prior to giving medication to ensure the medication was the right drug, at the right dose, given by the right route (for example, by nasogastric tube vs. by mouth, etc.), at the right time, and for the right patient.