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Based on medical record review, facility policy review, and staff interview, the facility failed to ensure a registered nurse evaluated the nursing care of each patient (A0395).

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure a registered nurse evaluated the nursing care for one of 11 patients reviewed (Patient #2). The facility's census in Labor and Delivery was eight.

Findings include:

Review of the medical record of Patient #2, revealed the patient was admitted to Labor and Delivery on 06/21/23 at 8:00 PM for an induction of labor. At 8:21 PM, the patient was placed on an external fetal monitor and tocodynamometer to assess the fetal heart rate and uterine activity. Both the external fetal monitor and the tocodynamometer were held against the patient's abdomen with an elastic belly band. A nurse's note at 3:05 PM stated a resident obstetric physician was at the bedside of the patient attempting to perform a vaginal exam, however, the patient was unable to tolerate the exam rating her pain from contractions as a five to six on a scale of zero to 10. An order was received that the patient could have an epidural placed. An intravenous fluid bolus was initiated in preparation for the epidural. At 3:43 PM, a certified registered nurse anesthetist (CRNA) was at the bedside of the patient to administer the epidural. The epidural was in place at 4:38 PM. The patient reported pain relief and was able to tolerate a vaginal exam. The patient was one centimeter dilated at the time the medication was placed.

A nurse's note, composed by Staff I at 7:13 PM on 06/22/23, revealed the nurse received report from the dayshift nurse and assumed care of the patient. At 8:28 PM, the labor flowsheet noted the patient continued to deny any pain from contractions, however, at 9:03 PM she reported pain, rating it as a four on a scale of zero to 10. A nurse's note at 11:54 PM stated an obstetric physician performed an artificial rupture of membranes (AROM). The patient four centimeters dilated at that time. At 1:30 AM on 06/23/23, a CRNA was notified of the patient's complaint of increased pain. The CRNA was at the bedside of the patient nine minutes later, at 1:39 AM to redose the epidural. According to the Medication Administration Record (MAR), Pitocin (a synthetic hormone that stimulates the uterine muscles to contract) was initiated at 2 milliunits per minute at 2:10 AM as ordered by the obstetric physician. A nurse's note at 4:03 AM stated the patient was seven to eight centimeters dilated. The note further stated the resident obstetric physician was notified and Staff I was instructed to check the patient's cervix in one hour. The patient rated her pain from contractions as a three on a scale of zero to 10 at 4:21 AM. A nurse's note at 5:06 AM, composed by Staff I, stated a k-pad, or water circulating heat pad with a pump, was placed due to the patient's complaint of pain. The medical record lacked documentation a physician ordered this heat device. At 5:34 AM, the labor flowsheet noted a CRNA was contacted to request a redose in the epidural due to the patient's complaint of pain. The CRNA was at the bedside of the patient at 5:47 AM. A nurse's note, composed by Staff J at 7:15 AM, stated she received report from Staff I and assumed care of Patient #2. Downtime documentation, at 8:18 AM, revealed the patient was sitting up for placement of a new epidural. The note stated: "rash with bubbling noted to right hip area." A border around the area was marked and a family practice physician was notified.

A certified nurse midwife's (CNM) progress note at 3:05 PM on 06/23/23 stated she was called by nursing staff to evaluate the patient for a rash/lesions on the patient's right hip. The CNM described the patient as "talkative" and a "good historian." The CNM stated that the patient reported having a heating pad placed on her right lower back during labor. The wound, with approximate measurements of 12-14 centimeters in length by 6 centimeters in width, was noted to be a burn. A wound consult was ordered.

The wound care nurse was at the bedside of the patient at 3:30 PM. Her note stated the reason for consultation was "possible third degree burn on right hip from hospital heating pad after epidural placement." The note further stated the patient denied any pain and appeared in no distress.

A family medicine resident from a tertiary facility was also consulted. The resident's note stated he was consulted to assist in the management of a thermal burn. It was also noted that the patient denied pain to the area but "given this lack of pain to significantly damaged tissue, this is most consistent with a full-thickness burn."

A debridement of the burn was performed on 06/26/23, prior to the patient being discharged home.

Further review of the medical record of Patient #2 revealed two outpatient visits to the wound clinic for follow up care on 06/29/23 and on 07/06/23.

Staff K was interviewed on 07/03/23 at 4:40 PM. She was asked if it was normal protocol to provide heat therapy after placement of an epidural. Staff K stated this was not normal and she would never advise using a heat pack after an epidural. Staff K was asked if this advice was in a written policy and she replied she was unaware of a written policy, however, stated it was "common sense."

Patient #2 was interviewed via phone on 07/06/23 at 2:16 PM. Patient #2 stated that her labor and delivery at the facility was "not a great experience." The patient revealed that she received a third degree burn on her back after laying on a heating pad. The patient described being very uncomfortable throughout the night despite having an epidural. She recalled Staff I placing a heating pad on her lower back. Patient #2 stated Staff I placed the heating pad under the belly band that held the fetal monitor in place in order to hold the heating pad directly on her back. Patient #2 was asked if she recalled the time the heating pad was placed under the belly band and she replied she was unsure of an exact time but thought it was at approximately 3:00 AM. She stated that later that morning, a staff nurse discovered she had a large reddened area on her back, where the heating pad had been placed. The patient also explained that some time during the evening of 06/23/23, a wound nurse examined the wound and determined it was a third degree burn from the heating pad. She stated although the epidural was wearing-off, she was "numb" and didn't feel the burn from the heating pad. Patient #2 reported a physician debrided the wound prior to discharge, on 06/26/23, and she had one follow-up appointment on 06/29/23 and was currently on her way to a second follow-up appointment.

Staff I was interviewed on 07/07/23 at 12:45 PM. According to Staff I, she received training with the water circulating heat pad with pump, or k-pad, during orientation. Although Staff I did not recall the name of the preceptor that provided the training as there were many preceptors, she did recall the preceptor demonstrating the k-pad set-up and how to use the equipment. Staff I denied that the preceptor provided any education on any precautions for the use of the k-pad. Staff I reported that Patient #2 required a lot of care during the night of 06/22/23 going into 06/23/23. Staff I did not recall if there was an order for the k-pad or not. She stated that she retrieved the pump for the water circulating heat pad from the supply closet on the unit. Staff I called the front desk and requested that the health unit coordinator (HUC) order the pad that connected to the pump from Central Supply. The pad was directly delivered to the room. Staff I stated she did not recall when she removed the heating pad from the patient's back but knew it was before giving report to the day shift nurse taking over care of the patient. Staff I revealed that she had a meeting with management since she cared for Patient #2 and was told only that she must get an order prior to using a k-pad.

The facility policy titled, Heat and Cold Therapy Application, review/revised on 05/2021, was reviewed on 07/03/23 at 6:00 PM. According to the policy, application of heat and/or cold therapies may be used to treat pain, swelling, or other symptoms, as appropriate. Nurses or designee should apply heat and cold therapies in a safe and effective manner. Standard equipment is used to apply heat and/or cold therapies to obtain consistent and safe temperatures and prevent thermal injury. In the policy section titled assessment/planning, at #3, nursing staff members were advised to assess patient for risk factors, including decreased circulation, numbness or decreased sensation, medical conditions that can affect patient's ability to sense heat or cold (e.g., diabetes, neuropathies, anemia, Raynaud's phenomena, hypothyroidism, etc.), or advanced age, as these factors increase the risk of burns/injury to skin integrity during heat or cool therapy. Nursing staff members are further advised to collaborate with physician, nurse practitioner, physician assistant and obtain order for heat or cold therapy, as needed. A table listed various types of heat and cold therapies on the left column while the right column heading asked if an order is needed. Next to each heat or cold therapy, yes or no indicated whether an order was required. Under heat therapy, warm blankets, instant warm pack, and water circulating heat pad with pump were listed. Although nursing staff members were advised an order was not needed for a warm blanket or instant warm pack, a water circulating heat pad with pump required an order. The policy further instructed nursing staff to educate patients/ family that a patient should not lie on the heating pad, as this may result in high temperature and an increased risk of injury. Nursing staff were advised to limit the time for heat application. Usually heat treatments should be used for 20-30 minutes at one time, which was in bold print, and may be re-applied every 2-4 hours, as needed. Nursing staff were instructed to monitor the patient closely to evaluate patient's tolerance of heat therapy and to identify potential skin injury. Nursing staff should re-assess the treatment site for areas of pain or persistent blanching. This may suggest temperature-related tissue injury has occurred. In the event these symptoms are noted, nursing staff should discontinue use of heat therapy immediately, re-evaluate for blanching or other skin discoloration after the skin temperature has returned to normal. Nursing staff were instructed to notify a physician, if persistent skin color changes were present.

Staff J was interviewed on 07/06/23 at 2:30 PM. According to Staff J, initially she believed the area on the patient's back to be a rash. She reported notifying a family practice physician and resident requesting that they come to the bedside to assess the area on the patient's back. After the patient informed staff members that she had been laying on a heating pad, Staff J reported searching for the heating pad. She reported there was no sign of the heating pad in the room.

Staff B and Staff G were interviewed on 07/06/23 at 11:30 AM. It was confirmed that the medical record lacked documentation there was an order for the heating pad placed on Patient #2. It was confirmed that given the specified patient was numb from an epidural, the heating pad should not have been applied, as the facility policy indicates numbness increases the risk of burns. It was confirmed that from 5:06 AM to at least 7:00 AM, the medical record lacked documentation the patient was closely monitored.

This deficiency represents non-compliance investigated under Substantial Allegation OH00144054.