HospitalInspections.org

Based on medical record review, document review and staff interview, it was determined that the registered nurse (RN) failed to supervise and evaluate the nursing care for 1 of 8 patients (Patient #1) in the sample. Findings included:

The hospital job description entitled "Professional Nurse..." stated, "...The Nurse plans and evaluates the nursing care for patients and families and exercises independent judgment in implementing the care...performs duties and tasks in accordance with performance standards...Documentation is accurate and complete..."

Medical record review revealed the following:

A. Patient #1

1. Physician order's to obtain/test stool (feces) for occult blood (blood in bowel movement that is not visibly apparent):
- 1/21/14 at 2:00 PM: obtain a stool specimen for occult blood
- 1/23/14 at 10:00 AM: obtain a stool specimen for occult blood
- 2/8/14 at 11:15 AM: obtain stool specimens for occult blood 3 times; notify physician if results positive for blood

Review of the medical record revealed:
- no evidence that stools were tested for occult blood as ordered by the physician

On 3/14/14 at 1:44 PM, Director A and Director of Quality Management A reviewed the medical record and confirmed this finding.

2. Physician order's for right heel wound care:
- 1/23/14: flush with saline solution, apply Aquacel?Ag (an antimicrobial dressing for infected wounds)

- 2/4/14 at 2:40 PM: daily flush with saline solution, pack wound with 1/4 inch packing, apply a 4x4 gauze dressing, wrap with Kerlix gauze bandage followed by an ACE (elastic) bandage wrap

On 3/14/14 at 2:20 PM, Director A reported that it was the expectation with wound dressing changes that the nurse assess and document the description of the wound, "what the wound looks like" including drainage and erythema (redness).

Review of the medical record revealed:
- no evidence that the nurse clarified the 1/23/14 physician's order for wound care (no ordered frequency for right heel dressing changes)
- no evidence that the nurse provided wound care to the right heel on 1/27, 2/1 and 2/7/14
- no evidence of nursing assessments of the right heel wound during dressing changes on: 1/24, 1/25, 1/28, 1/30, 1/31, 2/2, 2/6, 2/8, 2/9, 2/11, 2/12, 2/13, 2/14 and 2/15/14

On 3/14/14 at 2:40 PM and on 3/18/14 at 10:15 AM, Director A and Director of Quality Management A reviewed the medical record and confirmed these findings.

3. Physician order for daily weights on 2/8/14 at 3:00 PM

Review of the medical record revealed:
- no evidence that nursing staff obtained ordered weights on 2/11, 2/12 and 2/13/14

On 3/14/14 at 1:30 PM, Director A and Director of Quality Management A reviewed the medical record and confirmed this finding.

4. Physician order dated 2/10/14 at 11:30 AM for oral fluid restriction of 1200 ml (milliliters) of fluid per day

Review of the medical record revealed that nursing staff failed to monitor oral intake on:
2/12/14: oral intake of 2060 ml (excess of 860 ml)
2/13/14: oral intake of 2040 ml (excess of 840 ml)

On 3/18/14 at 10:15 AM, Director A and Director of Quality Management A reviewed the medical record and confirmed this finding.

5. No physician order for administration of oxygen

Review of the medical record revealed:
- nursing documented the application of oxygen via nasal cannula (prongs) with a flow rate between 2 liters and 4 liters on 1/22 and 1/24 - 2/4/14
- no evidence in the medical record that the nurse obtained an order for oxygen

On 3/14/14 at 1:40 PM, Director A and Director of Quality Management A reviewed the medical record and confirmed this finding.

6. Pulmonary (lungs) assessment

On 3/18/14 at 10:45 AM, Director A reported that based on the patient's chest x-ray and fluid overload, the expectation would be that a lung assessment be performed daily by nursing staff.

Review of the medical record revealed:
- no pulmonary assessments by nursing staff on 1/27 - 1/28, 1/31 - 2/1, 2/4 - 2/9, 2/12 and 2/15/14

On 3/18/14 at 10:45 AM, Director A and Director of Quality Management A reviewed the medical record and confirmed this finding.

7. Physician order dated 2/14/14 at 1:01 PM to discontinue the PICC line (peripherally inserted central catheter) - a form of intravenous (IV) access

On 3/18/14 at 10:50 AM, IV Team Leader A reported that the hospital followed the INS (Infusion Nurses Society) clinical standards for PICC line removal.

The INS policy and procedure entitled "Vascular Access Device Removal" stated, "...short peripheral...catheter...Assess integrity of removed catheter. Compare length of catheter to original insertion length to ensure entire catheter is removed...document procedure in patient's permanent medical record."

Review of the medical record revealed:
- 1/24/14 at 12:40 PM: radiology documentation included the insertion of a PICC line catheter; length of catheter recorded at 45 centimeters
- 2/14/14 at 11:00 PM: progress note from IV team member - PICC line removed "per protocol"
- no evidence in the medical record that the PICC line was measured at the time of removal

On 3/18/14 at 10:50 AM and 11:20 AM, IV Team Leader A, Director A and Director of Quality Management A reviewed the medical record and confirmed this finding.

Based on medical record review, policy review and staff interview, it was determined that for 2 of 8 patients (Patient #'s 1 and 2) in the sample that required a plan of care, staff failed to develop and/or revise the plan of care to reflect current needs. Findings include:

The hospital policy entitled "Patient Care Plans..." stated, "...A Patient Plan of Care incorporating Nursing Diagnoses is initiated by an RN (registered nurse) for each patient within 24 hours of admission...The Form...One or more Nursing Diagnoses are assigned based upon problems identified from the 'Interdisciplinary Admission Assessment' which require nursing intervention...Patient Care Plans must be re-evaluated/updated as needed or at least every three days by the RN or LPN (licensed practical nurse)..."

Medical record review revealed:

A. Patient #1

1. "Interdisciplinary Admission Assessment", completed by the RN on 1/21/14, revealed:
- patient anticipated being discharged to a long term care facility post-hospitalization
- diagnosis of diabetes, requiring the use of insulin injections daily at bedtime
- legally blind
- adult son responsible for anticipated learning needs
- diminished breath sounds in both lungs
- patient was depressed and concerned about his/her leg
- patient reported being non-ambulatory (unable to walk) prior to hospital admission
- patient reported a decline in ability to bathe, dress and perform household chores

2. Care Plan Problem: Discharge Planning

a. Review of the medical record revealed:
- 1/23/14: patient refused to divulge financial information to long term care facility and the Medicaid process could not move forward; facility reported to hospital that they would not take patient back
- 1/27/14: patient reported to social worker that there were sufficient funds to move to a hotel or rent an apartment, but refused to return to long term care
- additional discharge planning notes dated 1/31, 2/5, 2/6, 2/7, 2/10, 2/14 and 2/15/14 revealed that the patient was to be discharged to the community with home health care

b. Plan of care:
- failed to be revised to include a change in the patient's discharge disposition

3. Care Plan Problem: Knowledge Deficit

a. Plan of care failed to address:
- education provided by staff to the adult son regarding insulin preparation and administration or;
- evaluation of adult son's skill level: drawing up the correct dose of insulin in syringe, return demonstration of insulin administration

4. Care Plan Problem: Respiratory (lungs)

a. A chest x-ray dated 1/22/14 at 8:36 AM included the following impression:
- small bilateral pleural effusions (accumulation of fluid in the chest or on the lung); additional opacity at the lung bases may represent atelectasis (one or more areas of lungs collapse or don't inflate properly) or infiltrate (filling of air spaces with fluid)

b. Review of the medical record revealed:
- patient required the use of oxygen via nasal cannula (prongs) at 2 - 4 liters on 1/22 and 1/24 - 2/4/14
- lung assessment findings: diminished breath sounds on 1/21 - 1/27, 1/29 - 1/30 and 2/2 - 2/3/14

c. Plan of care:
- failed to be revised to address the patient's respiratory needs

5. Care Plan Problem: Endocrine (diabetes)

a. Physician's orders for insulin, dated 1/21/14 at 11:50 AM, included:
- daily insulin at bedtime
- blood glucose (sugar) monitoring before meals and at bedtime
- administer insulin on a sliding scale based on ordered parameters

b. Plan of care:
- failed to address diabetes

6. Care Plan Problem: Renal (kidneys)

a. Review of the medical record revealed:
- 2/8/14 at 3:00 PM: physician's order for daily weights
- 2/10/14 at 11:30 AM: physician's order for an oral fluid restriction of 1200 milliliters in a 24 hour period

b. Plan of care:
- failed to address daily weights and fluid restrictions

7. Care Plan Problem: Gastrointestinal (GI - digestive system/bowels)

a. Review of physician's orders revealed:
- 1/23/14:
10:00 AM: GI consult for possible GI bleeding
11:22 AM: dulcolax pill (laxative) x 1 today
4:00 PM: miralax (laxative) daily
- 1/27/14:
12:29 PM: miralax increased from daily to three times a day for seven days, then back to daily; magnesium citrate (laxative) on 1/29/14 if no bowel movement on 1/27 and 1/28/14

b. Plan of care:
- failed to be revised to address GI problems

8. Care Plan Problem: Anxiety

a. Review of the medical record (Progress Notes) revealed the following:
- 1/27/14 at 3:00 AM: Patient with increased agitation and attempting to climb out of bed; attempts to calm unsuccessful; physician contacted
- 1/27/14 at 3:07 AM: Ativan (anxiety medication) administered intravenously (IV) for agitation as per physician's order
- 2/2/14 at 3:45 AM: Nurse documented that patient gets anxious at times
- 2/14/14 at 10:25 AM: Nurse documented that patient vomited undigested food; patient reported that he/she was upset about discharge disposition

b. Plan of care:
- failed to be revised to address the patient's anxiety and interventions utilized to calm fears

9. Care Plan Problem: Mobility

a. Review of the medical record revealed:
- physical therapy (PT) evaluation conducted on 1/22/14 noted ADL (activities of daily living) functional deficits in strength, coordination and balance; patient was non-ambulatory during the initial assessment
- 1/27/14 at 12:30 PM: physical therapist documented that transfers out of bed would be "best" using a slide board to a stretcher chair or a hoyer (mechanical) lift
- progress notes revealed patient was transferred with hoyer lift on 1/30 and 2/2/14
- 2/4/14 at 2:40 PM: physician's orders for weight bearing to tolerance on right foot

b. Plan of care:
- failed to be revised to include methods to be utilized by staff to perform safe transfers and the patient's weight bearing status following the incision and drainage of the right foot wound with biopsy

10. Care Plan Problem: ADL Deficit

a. Review of the occupational therapy evaluation conducted on 1/22/14 revealed:
- ADL functional deficits in strength, coordination, vision, perception, activity tolerance and varying degrees of assistance required to dress, bathe, sit and transfer

b. Plan of care:
- failed to address ADL deficits

On 3/14/14, Director A reviewed the medical record between 1:20 PM - 2:06 PM and confirmed these findings.

B. Patient #2

1. Care Plan Problem: Infection

a. "Interdisciplinary Admission Assessment" completed by the RN on 3/1/14 at 2:00 AM, included an assessment of the patient's skin. The skin description included the presence of a rash covering the patient's upper arms and legs bilaterally with "scratch marks".

b. Physician orders dated 3/1/14 at 3:25 PM included:
- diagnosis of dermatitis (inflammation of the skin) with possible scabies (highly contagious human itch mite)
- contact isolation

c. Plan of care:
- failed to be revised to include contact isolation

Interview with Director B on 3/18/14 at 2:20 PM confirmed this finding.

Based on medical record review, document review and staff interview, it was determined that the medical record failed to contain accurate information for 1 of 8 patients (Patient #2) in the sample. Findings include:

The hospital job description entitled "Professional Nurse..." stated, "...Documentation is accurate and complete..."

A. Review of Patient #2's medical record revealed:

1. Physician order dated 3/1/14 at 3:25 PM:
- contact isolation for scabies (highly contagious human mite)

2. No documented evidence that isolation precautions were in use from 3/1/14 at 4:00 PM through 3/4/14 at 6:00 AM

During an interview on 3/18/14 at 2:20 PM, Director B:
- reported that the patient was in contact isolation during the hospitalization
- confirmed that the medical record documentation for isolation precautions was inaccurate

Based on medical record review, document review and staff interview, it was determined that physician order entries in the medical record were not authenticated, timed and/or dated for 4 of 8 patients (Patient #'s 1, 2, 5 and 6) in the sample. Findings include:

The hospital's medical staff "Rules and Regulations" stated, "...Management of information...All orders...shall be in writing with both time and date...practitioner should sign date and time telephone orders within 48 hours..."

Medical record review revealed the following:

A. Patient #1

1. "Physician's Orders" failed to include the date and/or time of order authentication on:

- 1/21/14 (5 entries)
- 1/22/14 (2 entries)
- 1/23/14
- 1/24/14
- 1/27/14 (3 entries)
- 1/28/14
- 1/30/14 (2 entries)
- 2/3/14
- 2/4/14
- 2/9/14

2. "Physician's Orders" failed to include order authentication (date, time and signature) on:

- 1/24/14
- 1/26/14
- 2/1/14

Interview with Director of Quality Management A on 3/18/14 at 3:00 PM confirmed this finding.

B. Patient #2

1. "Physician's Orders" failed to include the date and/or time of order authentication on:

- 3/2/14
- 3/3/14

2. "Physician's Orders" failed to include order authentication (date, time and signature) on:

- 3/1/14
- 3/2/14

Interview with Clinical Review Analyst A on 3/18/14 at 2:15 PM confirmed this finding.

C. Patient #5

1. "Physician's Orders" failed to include order authentication (date, time and signature) on:

- 3/14/14 (2 entries)

Interview with Clinical Review Analyst A on 3/18/14 at 10:20 AM confirmed this finding.

D. Patient #6

1. "Physician's Orders" failed to include order authentication (date, time and signature) on:

- 3/9/14
- 3/10/14

Interview with Clinical Review Analyst A on 3/14/14 at 3:00 PM confirmed this finding.

Based on medical record review, policy review and staff interview, it was determined that for 2 of 3 discharged patients in the sample requiring home care (Patient #'s 7 and 8), the facility failed to provide the patient with a list of available home health agencies (HHAs). Findings include:

The hospital policy entitled "Case Management-Interdisciplinary Discharge Planning" stated, "...Care Manager or Social worker documents in the medical record the choices of post-acute provider to the patient and family and the selections of provider...by the patient or family shall be documented in the medical record..."

Medical record review revealed the following:

A. Patient #7

- "Physician's Orders" dated 12/24/13 at 9:36 AM included an order to "d/c (discharge) to home...w/(with) home care (St [Saint] Francis)..."

- no documented evidence in the medical record that the choice list of Medicare participating HHAs was presented to the patient and/or family

Interview with Case Manager A on 3/18/14 at 1:40 PM confirmed this finding.

B. Patient #8

- "Discharge Instructions/Transition Record" dated 12/10/13 indicated in the "Appointment/Follow Up" section, the patient's "Home Care" choice as "Saint Francis Home Care"

- no documented evidence in the medical record that the choice list of Medicare participating HHAs was presented to the patient and/or family

Interview with Director of Social Work A on 3/18/14 at 1:15 PM confirmed this finding.