HospitalInspections.org

Based on clinical record review and staff interview the facility failed to take actions aimed at improvement and to conduct appropriate and accurate root cause analysis resulting in the implementation of appropriate preventive actions for 1 of 10 sampled patients (#4).

The findings include:
Review of Patient # 4's clinical record, conducted on 07/18/11, revealed the patient was admitted to the Telemetry Unit from the Emergency Department on 07/21/10 at 0333 hours.
Physician Orders dated 07/21/10 documents 1) Duoderm every three days to left leg burn and 2) leave blister intact.

Wound Care Consult dated 07/21/10 at 1330 documents " Seen per request for blistered area left anterior leg. Patient now has two areas of very superficial skin loss previously blistered. Anterior 2.0 centimeters (cm) by 1.5 cm and distal 1.7 cm by 2.0 cm. There is also present at this time one large fluid blister approximately 4.0 cm by 3.0 cm, dressing applied. Patient had dressing to right foot-removed to reveal small slit approximately 0.5 cm x 0.1 cm x 0.1 cm on the right lateral heel plantar surface. Patient complained of excruciating pain when touched. There is no unusual warmth or redness noted. Duoderm dressing applied. Other than slit heel intact, both suspended and rationale for so explained.

Plastic Surgery Consult dated 07/21/10 documents, " Patient seen and examined. Burn to left leg. Duoderm dressing and leave blister intact " .

Further review of the clinical record failed to disclose nursing notes addressing the cause, time, or accounting for the burn to the patient's left leg. The clinical record does not contain evidence / documentation of the warm compress treatment administration and monitoring.

Interview with the Director of Risk Management (DRM) was conducted on 07/18/11 at 1245. The DRM stated, Patient # 4 sustained a burn while receiving heat therapy with a hot pack; the patient was recently admitted when the incident occurred and an incident report was immediately completed; the patient received a wound consult and treatment for the burn. In addition the DRM stated the costs of the treatments were absorbed by the hospital.

Review of the Facility Report dated 07/21/10 was conducted on 07/18/11. The Report reveals Patient # 4 while on the Telemetry Unit sustained a blister on 07/21/10 at 8 AM. The severity level is documented as " 2 " temporary minor harm/damage, burn thermal in nature of injury. The report notes, " The nurse received report from another nurse who stated a warm compress had been applied to the patient's left leg as per doctor's orders. " Patient complained to nurse that it was too hot, "she asked the Certified Nursing Assistant to put a sheet between patient's leg and compress. The aide put a pillow case between leg and compress. Subsequently, the day shift aide entered the room and he asked the nurse if she had seen the blisters on patient's left leg where the compress was. Upon assessment the nurse noted two areas that appeared to be blisters that had burst and another area with a fluid filled blister. Warm compress was removed." The Report documented the physician and the Director of the Unit/Nurse Manager was notified of the incident. The investigation was completed by the Director of Telemetry Services on 07/21/10. The investigation report documents as follows: "Advised of this on 07/21/10. Went in to see patient, who indeed did have two second degree burns to left lower leg, one was already burst, second vesicle was fluid clear filled. Met with patient to advise him of the burn, apologized for this outcome. Consult with Risk Manager. Physician advised. Wound care consult ordered RN and MD (Registered Nurse and Medical Doctor). Wound care physician in to see patient. Treatment orders received. Met with Registered Nurse and Aide who care for patient that evening. Reviewed responsibility and accountability, patient contributing factors, such as Diabetes and Peripheral Vascular Disease, diminished sensation ... They were most distraught about outcome. They were to meet with patient. I spoke with patient's wife and spoke to daughter on the phone to accept responsibility and to apologize and to review care and treatment plan. Also advised that all cost associated with this will be the hospital responsibility.

Review of the Annual Report summarizing incident reports for the 2010 calendar year submitted on 03/28/11 failed to disclose the inclusion of the incident related to Patient # 4.
A subsequent interview with the DRM was conducted on 07/18/11 at approximately 0130 hours. The DRM acknowledged the incident was not included on the annual report. The DRM further stated she was not sure why the incident was not reported and she was going to submit an amendment to correct the report.

Review of the Hospital Policy Titled "ANNUAL SUMMARY OF INCIDENTS TO AHCA " , most recently revised on 02/10 documented as follows: On an annual basis, the hospital is required to submit a Summary of Incidents to the Department of AHCA. This report will summarize those incidents occurring in the facility during the most recent year. The report will contain all pertinent information as required (See Format).
When filing the report, all names will be coded using the professional license number where applicable, or the social security number when needed. Only those incidents, which result in more than superficial injury to a patient, will be reported. Nosocomial infections, which cause severe adverse effects and prolong the patient's stay, are to be reported. Injuries and causes will be coded, using the International Classification of Disease -9 (ICD-9).

Communication between nurses and aides substantiate the nurse's failure to supervise and monitor the care rendered by the Certified Nursing Assistant. Review of the facility investigation disclosed the facility did not conduct appropriate "root cause analysis" regarding improper application of warm compress by the aide. The contributing factors identified by the facility includes Diabetes, Peripheral Vascular Disease and decrease sensation which did not contribute to the aide's inappropriate actions and nurse's failure to supervise the application of the hot / warm compress.

Based on clinical record review and staff interview the facility failed to ensure the quality of nursing care provided to each patient is supervised and evaluated in accordance with established standards of practice of nursing chapter 464.003(5), and the Certified Nursing Assistant failed to perform duties as authorized by chapter 64B9-15.002.

The findings include:

Review of Patient # 4's clinical record, conducted on 07/18/11, revealed the patient was admitted to the Telemetry Unit from the Emergency Department on 07/21/10 at 0333 hours in stable condition.

Physician Orders dated 07/21/10 at 1145 documents Wound Care Nurse and also Wound Care Consult regarding blisters left lower leg.
Physician Order dated 07/21/10 at 1330 documents wound care to left lower leg anterior aspect, Polymen to cover unrolled blisters and fluid filled blister until orders are received from wound care physician.
Physician Orders dated 07/21/10 documents 1) Duoderm every three days to left leg burn and 2) leave blister intact.

Wound Care Consult dated 07/21/10 at 1330 hours documents " Seen per request for blistered area left anterior leg. Patient now has two areas of very superficial skin loss previously blistered. Anterior 2.0 centimeters (cm) by 1.5 cm and distal 1.7 cm by 2.0 cm. There is also present at this time one large fluid blister approximately 4.0 cm by 3.0 cm, dressing applied. Patient had dressing to right foot-removed to reveal small slit approximately 0.5 cm x 0.1 cm x 0.1 cm on the right lateral heel plantar surface. Patient complained of excruciating pain when touched. There is no unusual warmth or redness noted. Duoderm dressing applied. Other than slit heel intact, both suspended and rationale for so explained".

Plastic Surgery Consult dated 07/21/10 documents, " Patient seen and examined. Burn to left leg. Duoderm dressing and leave blister intact " .

Further review of the clinical record failed to disclose nursing notes addressing the cause of the burn on the patient's left leg, or the time of its occurrence. The clinical record failed to document the application of a warm compress treatment applied and nursing monitoring of the compress.

During an interview with The Director of Risk Management (DRM) conducted on 07/18/11 at approximately 11 AM, it was revealed there is documentation of the incident on the Facility Report. Review of the Facility Report dated 07/21/10 revealed Patient # 4 while on the telemetry unit sustained a blister on 07/21/10 at 8 AM. The severity level is documented as " 2 " - temporary minor harm/damage, burn thermal in nature of injury. The report notes, "The nurse received report from another nurse who stated a warm compress had been applied to the patient's left leg as per doctor's orders. The patient complained to the nurse that the compress was too hot. The nurse asked the Certified Nursing Assistant to put a sheet between patient's leg and the compress. The aide put a pillow case betweenthe patient's leg and the compress. Subsequently, the day shift aide entered the patient's room the he asked the nurse if she had seen the blisters on the patient's left leg where the compress was. Upon assessment at this time, the nurse noted two areas that appeared to be blisters that had burst and another area with a fluid filled blister. Warm compress was removed."

The Facility Report documents the Physician and the Director of the Unit were notified of the incident. The facility investigation was completed by the Director of Telemetry Services on 07/21/10. The facility investigation report documents as follows: "Advised of this on 07/21/10. Went in to see patient, who indeed did have two second degree burns to left lower leg, one was already burst, second vesicle was fluid clear filled. Met with patient to advise him of the burn, apologized for this outcome. Consult with Risk Manager; physician advised. Wound care consult ordered RN and MD. Wound care physician in to see patient. Treatment orders received. Met with Registered Nurse and Aide who care for patient that evening. Reviewed responsibility and accountability, patient contributing factors, such as Diabetes and Peripheral Vascular Disease, diminished sensation. They were most distraught about outcome. They were to meet with patient. I spoke with patient's wife and spoke to daughter on the phone to accept responsibility, to apologize, and to review care and treatment plan. Also advised that all cost associated with this will be the hospital responsibility " .

Interview with the DRM was conducted on 07/18/11 at 12:45 PM. The DRM stated the patient sustained the burn right after his admission to the third floor and it was due to a hot pack. The DRM stated the incident report was filed immediately after the blisters were discovered and the hospital picked up the tab for any care and services related to the injury. The DRM stated there were no grievances on file for this patient.

Review of the counseling form for the Certified Nursing Assistant involved in the incident was conducted on 07/18/11. The document notes on 07/21/10 the Certified Nursing Assistant used a washcloth with hot water from the machine and put this into a covered protected ice bag. The water leaked out of the bag causing burns to the patient. The director and aide reviewed the proper protocol for testing warm compresses and that no staff was to use hot water. "Perry Potter warm and cold therapy and applying aquathermia and heating pads reviewed with the aide and copy provided with review." Reviewed/pointed signs posted on the machine that this water is not to be used for patient care. The follow-up packet includes teaching documentation on cultural considerations, skill performance guidelines, application of moist heat, assessments, care planning and implementation, recording and reporting treatments and unexpected outcomes.

Interview with Registered Nurse (RN # 4) who works on the Telemetry Unit was conducted on 07/18/11 at 1320 hours. The RN stated warm compresses are not frequently used, but if she needed one she would order one from central supply. She stated she would monitor the patient frequently for safety and she remembered receiving an in-service in regards to heat and cold compress use sometime last year.

Interview with Registered Nurse (RN) # 1 who works in the Telemetry Unit was conducted on 07/18/11 at 0252. The RN stated warm compresses are not frequently used. The RN stated if she needed to apply heat she would use the " Aquathermia machine. " The nurse stated the aides were typically the ones who would set up the machine, but as the nurse she would supervise the application and she would monitor the patient as well. The RN stated she received an in-service in regards to the application of heat and cold.

Interview with The Emergency Room Charge Nurse was conducted on 07/19/11 at 1135 hours. The charge nurse stated they don't frequently use warm compresses or heat packs. She stated "Aquathermia" was the method of choice and they were able to obtain the equipment from central supply. The charge nurse stated this machine has safety features and the emergency department nurses would not use hot water and towels to create a warm compress. The charge nurse stated there are no aides in the emergency department, only nurses and paramedics.

Interview with RN # 3 was conducted on 07/19/11 at 1205. The nurse stated she has worked at the hospital for three years and she could not recall an instance where she had to use warm compresses. She stated they were not frequently used. The nurse stated if she needs to apply heat to a patient she would use the "Aquathermia Machine". In addition she added the machine would be used for 10 minutes and she would frequently check on the patient to avoid injuries.

Interview with Certified Nursing Assistant, who discovered the burn on Patient # 4, was conducted on 07/19/11 at 1230. The aide stated if he had to apply warm compress to a patient, he would first verify the physician order. Then he would preferably use the " Aquathermia machine" which he could get from central supply. If that was not available he would use warm water and a towel. The aide stated he would never use hot water. The aide stated he would apply the compress for about ten minutes and he would frequently check the temperature. The aide stated if he was not sure of the protocol he would go in the director's office and read the protocol. The aide stated he remembered receiving an in-service in regards to heat and cold application, one when he was initially hired and another one last year after the incident.

Interview with The Director of Telemetry Services was conducted on 07/19/11 at 12:45 PM. The Director stated she provided in-services to her staff regarding the use of warm compresses. The Director stated she reviewed the Perry and Potter protocol for heat and cold therapies, cultural considerations, skill performance guidelines, application of moist heat, assessments, care planning and implementation, recording and reporting treatments and unexpected outcomes.

Communication between nurses and aides substantiate the nurse's failure to supervise and monitor the care rendered by the Certified Nursing Assistant. The practice of application of the hot / warm compress is not universal among staff.

Based on clinical record review and staff interview the facility failed to take actions aimed at improvement and to conduct appropriate and accurate root cause analysis resulting in the implementation of appropriate preventive actions for 1 of 10 sampled patients (#4).

The findings include:
Review of Patient # 4's clinical record, conducted on 07/18/11, revealed the patient was admitted to the Telemetry Unit from the Emergency Department on 07/21/10 at 0333 hours.
Physician Orders dated 07/21/10 documents 1) Duoderm every three days to left leg burn and 2) leave blister intact.

Wound Care Consult dated 07/21/10 at 1330 documents " Seen per request for blistered area left anterior leg. Patient now has two areas of very superficial skin loss previously blistered. Anterior 2.0 centimeters (cm) by 1.5 cm and distal 1.7 cm by 2.0 cm. There is also present at this time one large fluid blister approximately 4.0 cm by 3.0 cm, dressing applied. Patient had dressing to right foot-removed to reveal small slit approximately 0.5 cm x 0.1 cm x 0.1 cm on the right lateral heel plantar surface. Patient complained of excruciating pain when touched. There is no unusual warmth or redness noted. Duoderm dressing applied. Other than slit heel intact, both suspended and rationale for so explained.

Plastic Surgery Consult dated 07/21/10 documents, " Patient seen and examined. Burn to left leg. Duoderm dressing and leave blister intact " .

Further review of the clinical record failed to disclose nursing notes addressing the cause, time, or accounting for the burn to the patient's left leg. The clinical record does not contain evidence / documentation of the warm compress treatment administration and monitoring.

Interview with the Director of Risk Management (DRM) was conducted on 07/18/11 at 1245. The DRM stated, Patient # 4 sustained a burn while receiving heat therapy with a hot pack; the patient was recently admitted when the incident occurred and an incident report was immediately completed; the patient received a wound consult and treatment for the burn. In addition the DRM stated the costs of the treatments were absorbed by the hospital.

Review of the Facility Report dated 07/21/10 was conducted on 07/18/11. The Report reveals Patient # 4 while on the Telemetry Unit sustained a blister on 07/21/10 at 8 AM. The severity level is documented as " 2 " temporary minor harm/damage, burn thermal in nature of injury. The report notes, " The nurse received report from another nurse who stated a warm compress had been applied to the patient's left leg as per doctor's orders. " Patient complained to nurse that it was too hot, "she asked the Certified Nursing Assistant to put a sheet between patient's leg and compress. The aide put a pillow case between leg and compress. Subsequently, the day shift aide entered the room and he asked the nurse if she had seen the blisters on patient's left leg where the compress was. Upon assessment the nurse noted two areas that appeared to be blisters that had burst and another area with a fluid filled blister. Warm compress was removed." The Report documented the physician and the Director of the Unit/Nurse Manager was notified of the incident. The investigation was completed by the Director of Telemetry Services on 07/21/10. The investigation report documents as follows: "Advised of this on 07/21/10. Went in to see patient, who indeed did have two second degree burns to left lower leg, one was already burst, second vesicle was fluid clear filled. Met with patient to advise him of the burn, apologized for this outcome. Consult with Risk Manager. Physician advised. Wound care consult ordered RN and MD (Registered Nurse and Medical Doctor). Wound care physician in to see patient. Treatment orders received. Met with Registered Nurse and Aide who care for patient that evening. Reviewed responsibility and accountability, patient contributing factors, such as Diabetes and Peripheral Vascular Disease, diminished sensation ... They were most distraught about outcome. They were to meet with patient. I spoke with patient's wife and spoke to daughter on the phone to accept responsibility and to apologize and to review care and treatment plan. Also advised that all cost associated with this will be the hospital responsibility.

Review of the Annual Report summarizing incident reports for the 2010 calendar year submitted on 03/28/11 failed to disclose the inclusion of the incident related to Patient # 4.
A subsequent interview with the DRM was conducted on 07/18/11 at approximately 0130 hours. The DRM acknowledged the incident was not included on the annual report. The DRM further stated she was not sure why the incident was not reported and she was going to submit an amendment to correct the report.

Review of the Hospital Policy Titled "ANNUAL SUMMARY OF INCIDENTS TO AHCA " , most recently revised on 02/10 documented as follows: On an annual basis, the hospital is required to submit a Summary of Incidents to the Department of AHCA. This report will summarize those incidents occurring in the facility during the most recent year. The report will contain all pertinent information as required (See Format).
When filing the report, all names will be coded using the professional license number where applicable, or the social security number when needed. Only those incidents, which result in more than superficial injury to a patient, will be reported. Nosocomial infections, which cause severe adverse effects and prolong the patient's stay, are to be reported. Injuries and causes will be coded, using the International Classification of Disease -9 (ICD-9).

Communication between nurses and aides substantiate the nurse's failure to supervise and monitor the care rendered by the Certified Nursing Assistant. Review of the facility investigation disclosed the facility did not conduct appropriate "root cause analysis" regarding improper application of warm compress by the aide. The contributing factors identified by the facility includes Diabetes, Peripheral Vascular Disease and decrease sensation which did not contribute to the aide's inappropriate actions and nurse's failure to supervise the application of the hot / warm compress.

Based on clinical record review and staff interview the facility failed to ensure the quality of nursing care provided to each patient is supervised and evaluated in accordance with established standards of practice of nursing chapter 464.003(5), and the Certified Nursing Assistant failed to perform duties as authorized by chapter 64B9-15.002.

The findings include:

Review of Patient # 4's clinical record, conducted on 07/18/11, revealed the patient was admitted to the Telemetry Unit from the Emergency Department on 07/21/10 at 0333 hours in stable condition.

Physician Orders dated 07/21/10 at 1145 documents Wound Care Nurse and also Wound Care Consult regarding blisters left lower leg.
Physician Order dated 07/21/10 at 1330 documents wound care to left lower leg anterior aspect, Polymen to cover unrolled blisters and fluid filled blister until orders are received from wound care physician.
Physician Orders dated 07/21/10 documents 1) Duoderm every three days to left leg burn and 2) leave blister intact.

Wound Care Consult dated 07/21/10 at 1330 hours documents " Seen per request for blistered area left anterior leg. Patient now has two areas of very superficial skin loss previously blistered. Anterior 2.0 centimeters (cm) by 1.5 cm and distal 1.7 cm by 2.0 cm. There is also present at this time one large fluid blister approximately 4.0 cm by 3.0 cm, dressing applied. Patient had dressing to right foot-removed to reveal small slit approximately 0.5 cm x 0.1 cm x 0.1 cm on the right lateral heel plantar surface. Patient complained of excruciating pain when touched. There is no unusual warmth or redness noted. Duoderm dressing applied. Other than slit heel intact, both suspended and rationale for so explained".

Plastic Surgery Consult dated 07/21/10 documents, " Patient seen and examined. Burn to left leg. Duoderm dressing and leave blister intact " .

Further review of the clinical record failed to disclose nursing notes addressing the cause of the burn on the patient's left leg, or the time of its occurrence. The clinical record failed to document the application of a warm compress treatment applied and nursing monitoring of the compress.

During an interview with The Director of Risk Management (DRM) conducted on 07/18/11 at approximately 11 AM, it was revealed there is documentation of the incident on the Facility Report. Review of the Facility Report dated 07/21/10 revealed Patient # 4 while on the telemetry unit sustained a blister on 07/21/10 at 8 AM. The severity level is documented as " 2 " - temporary minor harm/damage, burn thermal in nature of injury. The report notes, "The nurse received report from another nurse who stated a warm compress had been applied to the patient's left leg as per doctor's orders. The patient complained to the nurse that the compress was too hot. The nurse asked the Certified Nursing Assistant to put a sheet between patient's leg and the compress. The aide put a pillow case betweenthe patient's leg and the compress. Subsequently, the day shift aide entered the patient's room the he asked the nurse if she had seen the blisters on the patient's left leg where the compress was. Upon assessment at this time, the nurse noted two areas that appeared to be blisters that had burst and another area with a fluid filled blister. Warm compress was removed."

The Facility Report documents the Physician and the Director of the Unit were notified of the incident. The facility investigation was completed by the Director of Telemetry Services on 07/21/10. The facility investigation report documents as follows: "Advised of this on 07/21/10. Went in to see patient, who indeed did have two second degree burns to left lower leg, one was already burst, second vesicle was fluid clear filled. Met with patient to advise him of the burn, apologized for this outcome. Consult with Risk Manager; physician advised. Wound care consult ordered RN and MD. Wound care physician in to see patient. Treatment orders received. Met with Registered Nurse and Aide who care for patient that evening. Reviewed responsibility and accountability, patient contributing factors, such as Diabetes and Peripheral Vascular Disease, diminished sensation. They were most distraught about outcome. They were to meet with patient. I spoke with patient's wife and spoke to daughter on the phone to accept responsibility, to apologize, and to review care and treatment plan. Also advised that all cost associated with this will be the hospital responsibility " .

Interview with the DRM was conducted on 07/18/11 at 12:45 PM. The DRM stated the patient sustained the burn right after his admission to the third floor and it was due to a hot pack. The DRM stated the incident report was filed immediately after the blisters were discovered and the hospital picked up the tab for any care and services related to the injury. The DRM stated there were no grievances on file for this patient.

Review of the counseling form for the Certified Nursing Assistant involved in the incident was conducted on 07/18/11. The document notes on 07/21/10 the Certified Nursing Assistant used a washcloth with hot water from the machine and put this into a covered protected ice bag. The water leaked out of the bag causing burns to the patient. The director and aide reviewed the proper protocol for testing warm compresses and that no staff was to use hot water. "Perry Potter warm and cold therapy and applying aquathermia and heating pads reviewed with the aide and copy provided with review." Reviewed/pointed signs posted on the machine that this water is not to be used for patient care. The follow-up packet includes teaching documentation on cultural considerations, skill performance guidelines, application of moist heat, assessments, care planning and implementation, recording and reporting treatments and unexpected outcomes.

Interview with Registered Nurse (RN # 4) who works on the Telemetry Unit was conducted on 07/18/11 at 1320 hours. The RN stated warm compresses are not frequently used, but if she needed one she would order one from central supply. She stated she would monitor the patient frequently for safety and she remembered receiving an in-service in regards to heat and cold compress use sometime last year.

Interview with Registered Nurse (RN) # 1 who works in the Telemetry Unit was conducted on 07/18/11 at 0252. The RN stated warm compresses are not frequently used. The RN stated if she needed to apply heat she would use the " Aquathermia machine. " The nurse stated the aides were typically the ones who would set up the machine, but as the nurse she would supervise the application and she would monitor the patient as well. The RN stated she received an in-service in regards to the application of heat and cold.

Interview with The Emergency Room Charge Nurse was conducted on 07/19/11 at 1135 hours. The charge nurse stated they don't frequently use warm compresses or heat packs. She stated "Aquathermia" was the method of choice and they were able to obtain the equipment from central supply. The charge nurse stated this machine has safety features and the emergency department nurses would not use hot water and towels to create a warm compress. The charge nurse stated there are no aides in the emergency department, only nurses and paramedics.

Interview with RN # 3 was conducted on 07/19/11 at 1205. The nurse stated she has worked at the hospital for three years and she could not recall an instance where she had to use warm compresses. She stated they were not frequently used. The nurse stated if she needs to apply heat to a patient she would use the "Aquathermia Machine". In addition she added the machine would be used for 10 minutes and she would frequently check on the patient to avoid injuries.

Interview with Certified Nursing Assistant, who discovered the burn on Patient # 4, was conducted on 07/19/11 at 1230. The aide stated if he had to apply warm compress to a patient, he would first verify the physician order. Then he would preferably use the " Aquathermia machine" which he could get from c