HospitalInspections.org

Based on staff interview, review of medical records, and review of the nursing facility death records, it was determined the hospital failed to ensure all nursing requirements were met. There lacked evidence nursing staff provided the necessary assessment, monitoring, and nursing measures to ensure adequate bowel management for 1 of 7 sample patients (#3) (A395). In addition, the hospital administered antipsychotic medication to 1 of 7 sample patients (#3) just prior to discharge without adequate documentation of necessity (A405). This lack of appropriate nursing assessment, monitoring, and nursing care may have contributed to the patient's death within less than 24 hours of discharge. The combined results of these systems failures resulted in the inability of the hospital to meet all of the necessary requirements for the Nursing Services Condition of Participation.

Based on staff interview, review of medical records, and review of the nursing facility death records, it was determined the hospital failed to ensure an effective discharge planning process was in place for 1 of 7 sample patients (#3) in regard to reassessment (A821). This lack of effective planning may have contributed to the death of 1 sample patient (#3) who expired in less than 24 hours after discharge. The combined results of these systems failures resulted in the inability of the hospital to meet all of the necessary requirements for the discharge planning services Condition of Participation.

Based on staff interview, medical record review, and review of the nursing facility death records, the hospital failed to ensure nursing assessment, monitoring, and implementation of nursing measures were provided for 1 of 7 sample patients (#3). The findings were:

Review of the medical record showed patient #3 was admitted on 5/21/13 with diagnoses including lumbar spinal stenosis, lumbar radiculopathy, lumbar spondylosis, and neurogenic claudication. Review of the operative report showed the patient had a complete L4 decompressive lumbar laminectomy with bilateral open facet rhizotomies, medial facetectomies, and foraminotomies performed on 5/21/13. On 5/25/13 the patient had an unplanned additional surgical procedure which included exploration of the lumbar wound and L3 decompression with L2-L3 diskectomy. The following concern was identified:
Review of the physician's post-operative orders dated 5/21/13 and timed at 10:15 AM showed bowel management orders included Colace 100 mg twice daily when able to take oral fluids. In addition, there was an order that "If no BM [bowel movement] by 2nd day post-op start bisacodyl suppository 1 per rectum BID [twice daily] until patient has results." Review of the 5/21/13 physician's standing orders, also timed at 10:15 AM, showed bowel management orders for Colace 100 mg twice daily as needed and could use liquid if the patient was unable to swallow a tablet. Also ordered was MOM (milk of magnesia) 30 ml (milliliters) daily as needed, bisacodyl 10 mg rectal suppository as needed, magnesium citrate 1/2 to 1 bottle daily as needed, and finally a Fleets enema per rectum every 2nd day as needed.
Review of the nursing notes showed the patient had a BM on the day of admission but not again for 7 days; the patient had no BM as of the time of discharge on 5/28/13. Review of the May 2013 MAR showed the patient was administered Colace and a bisacodyl suppository at 2:56 PM on 5/21/13 and MOM on that same day at 8:13 PM. The patient was administered the Colace twice daily as ordered. The patient received MOM on 5/26/13, 5/27/13 and on 5/28/13. However, none of these medications were effective in producing a BM.
Review of the 5/27/13 nursing notes timed at 7 AM showed the patient was bloated and constipated. Review of the physician's orders dated 5/27/13 showed the nurse activated the standing order for magnesium citrate (previously ordered) at 6:57 AM. Review of the 5/27/13 nursing notes timed at 7:26 PM showed the patient remained bloated and constipated and had no flatus. On 5/28/13 at 7:45 AM the nursing notes indicated the patient was nauseous, had a distended and firm abdomen, and was constipated. Review of the 5/28/13 physical therapy notes timed at 9:25 AM showed "unable to fit brace at this time d/t [due to] abd [abdominal] distention." There was no evidence any interventions other than the routine Colace and the PRN MOM and magnesium citrate were provided despite having other physician orders available if these medications were ineffective. Review of the physician's post-operative orders showed a specific order for the patient to have bowel treatments until there were results after the 2nd post-operative day, including a Fleets enema if necessary. The patient was discharged on 5/28/13 at 10:23 AM to a nursing home without having had a BM for 7 days and had experienced bloating, nausea, abdominal distention and firmness significant enough to make it impossible for the physical therapist to place the lumbar brace on the patient. Interview with the DON on 10/23/13 at 10:20 AM revealed it was unacceptable to allow a patient to go 7 days without a BM, especially when there were physician orders available for use. The DON further stated it should not have happened and he was unsure why the patient was discharged without having had a BM post-operatively. Review of the nursing facility death record showed the patient's abdomen was distended and tender upon admission. The nursing facility physician ordered a double Fleets enema "now" on 5/28/13, the day of admission. According to the nursing facility nursing notes, the patient was found dead at 4:20 AM on the morning of 5/29/13, less than 24 hours after transfer from the hospital.

Based on staff interview, medical record review, and review of the nursing facility death records, the hospital failed to ensure PRN antipsychotic medications administered were necessary for 1 of 7 sample patients (#3). The findings were:

Review of the updated history and physical performed on 5/21/13 for patient #3 showed the patient's mental status was normal for age and situation. Review of the pre-operative nursing assessment showed the patient had no memory deficits, responded appropriately, and followed directions. Review of the 5/22/13 nursing notes timed at 8 AM showed the patient's speech pattern, behaviors, and mood were all appropriate. Review of the 5/23/13 nursing assessment timed at 8:45 AM showed the patient's speech pattern and mood were appropriate and his/her behaviors were cooperative. Review of the 5/23/13 nursing assessment timed at 8 PM showed the patient was alert and oriented, his/her speech was clear, and his/her behaviors were appropriate. Review of the 5/24/13 nursing assessment timed at 7 AM, the 5/24/13 nursing assessment timed at 7 PM, and the 5/25/13 nursing assessment timed at 6:52 AM showed the patient continued to be appropriate and cooperative with mood and behaviors. Review of the post anesthesia care unit (PACU) notes showed on 5/25/13 at 8:13 PM, after the second surgical procedure (unplanned), the patient did become agitated and required antipsychotic medication in PACU. However, according to the 5/26/13 nursing assessment timed at 6:26 AM, the patient was cooperative with care, his/her speech pattern was appropriate and his/her mood was appropriate. Review showed no evidence the patient continued to be agitated or confused as s/he was immediately post-operatively. Review of the 5/26/13 nursing assessment timed at 6:59 PM, the 5/27/13 nursing assessment timed at 5:03 AM, 7 AM, and again at 7:26 PM, all showed the patient was cooperative and appropriate with mood and behaviors but was somewhat drowsy. Review of the 5/28/13 nursing assessment timed at 7:45 AM showed the patient's mood and behaviors were appropriate. However, review of the MAR showed the patient was administered haldol, an antipsychotic medication used for psychosis, on 5/28/13 at 7:02 AM, the day of discharge to a nursing home. Review of the entire medical record showed no rationale for the necessity of the medication haldol. In addition, interview with the DON on 10/23/13 at 10:20 AM revealed he did not know why the haldol was given. He verified there was no evident rationale for the antypsychotic medication that was administered to the patient at that time. Review of the nursing facility death record showed the patient was lethargic but responsive upon admission. According to the nursing facility nursing notes, the patient was found dead at 4:20 AM on the morning of 5/29/13, less than 24 hours after being transferred from the hospital.

Based on staff interview, medical record review, and review of the nursing facility death records, the hospital failed to ensure effective discharge planning needs were implemented for 1 of 7 sample patients (#3). The findings were:

Review of the medical record showed patient #3 was admitted on 5/21/13 with diagnoses including lumbar spinal stenosis, lumbar radiculopathy, lumbar spondylosis, and neurogenic claudication. Review of the 5/21/13 operative report showed the patient had a complete L4 decompressive lumbar laminectomy with bilateral open facet rhizotomies, medial facetectomies, and foraminotomies performed. On 5/25/13 the patient had an unplanned additional surgical procedure which included exploration of the lumbar wound and L3 decompression with L2-L3 diskectomy. Review of the 5/21/13 multidisciplinary discharge planning form showed resident #3 was independent and alert. Further review showed "No needs voiced @ this time." However, review of the medical record showed the patient had an unplanned second surgical procedure on 5/25/13, had a decline in physical mobility after the second surgery, and had significant issues with constipation. The following concerns with discharge planning were identified:
a. Review of the physical therapy progress notes dated 5/28/13 (day of discharge) and timed at 9:25 AM (approximately 1 hour prior to discharge) showed the patient required increased assistance for all mobility that morning. The patient leaned to the left throughout the entire treatment and required maximum assistance of two to manage his/her walker and to stand upright without leaning to the left. All transfers required maximum assistance. Review of the medical record showed the resident had previously been independent with ambulation and mobility. There was no evidence in the medical record that the patient's discharge planning needs were re-assessed after the second surgical procedure was performed and his/her change in condition.
b. The patient was discharged to a nursing home on 5/28/13 at 10:23 AM without having had a BM for 7 days and had experienced bloating, nausea, abdominal distention and firmness significant enough to make it impossible for the physical therapist to place the lumbar brace on the patient that morning. There was no evidence in the medical record that the patient's discharge planning needs were re-assessed after his/her change in condition.
c. During an interview with the 2 case managers on 10/23/13 at 10:05 AM, they both acknowledged their had been recent issues with the discharge planning process and changes were made. They acknowledged some of the patient needs were missed or not addressed adequately, including this patient.
d. Review of the nursing facility death records showed the patient was lethargic upon admission, his/her abdomen was distended and tender, and s/he was found dead at 4:20 AM on the morning of 5/29/13, less than 24 hours after transfer from the hospital.