HospitalInspections.org

This Standard is not met as evidenced by:

Based on record review and staff interview, it was determined the facility failed to maintain patient care equipment.

Findings include:

1. On 05/10/15 at approximately 11:15 a.m., a review of the Medical Equipment log for the past twelve (12) months indicated that seven (7) items were past due for annual safety inspection.

2. These findings were discussed with the facility's Maintenance Director on 05/10/15 at approximately 11:20 a.m. where he agreed the equipment had not had an annual safety inspection.

A. Based on document review and staff interviews, it was determined the facility failed to ensure the Registered Nurse (RN) followed facility policy in assigning of a triage level (priority of treatment based on severity of the patient's condition) to one (1) of two (2) Emergency Department (ED) patients reviewed (Patient #8). Failure to prioritize care can place all patients presenting to the ED at risk of a delay in treatment of an emergency medical condition.

Findings include:

1. Facility Policy under Nursing, entitled, "Triage", last approved on 8/19/14, was reviewed on 6/10/15. It states, in part: "RN will prioritize the disposition of patients based on the following criteria: Resuscitation (Level 1), immediate threat to life. Emergent Criteria: (Level 2) Conditions which involve a significant risk of death to the patient, example a suicidal or homicidal patient."

2. The medical record of Patient #8 was reviewed on 6/10/15 and revealed the patient presented to the facility ED on 3/14/15 with a chief complaint of "Bad thoughts, onset yesterday, pt. states that she had feelings of wanting to hurt herself." Review of physician's note revealed the entry: "Patient presents to the emergency room today for wanting to run away and wanting to shoot herself." The record revealed an assigned triage level of three (3).

3. The above documentation was reviewed and discussed with the Chief Nursing Officer (CNO) on 6/10/15 at 12:20 p.m. at which time she concurred the triage level assigned for Patient #8 was incorrect and stated: "It should have been a two (2) per policy."

B. Based on document review and staff interview it was determined the facility failed to ensure the RN initiated a Precaution Level for observation of a patient presenting with suicidal ideations (thoughts), per facility policy, for one (1) of two (2) ED patients reviewed (Patient #8). Failure to initiate and communicate the need for close observation of a patient with self-destructive thoughts and/or behaviors places all such patients at risk of harm while awaiting treatment.

Findings include:

1. Facility policy under Nursing, entitled, "Mental Hygiene", last reviewed 8/2014, was reviewed on 6/10/15. It states, in part: "Procedure: Assess for presence of destructive, suicidal, or homicidal behavior, thoughts, verbalizations and/or intent upon entry to the department. Assess need to assign a 'Precaution' level. The level of precaution needed may be ordered by a physician or initiated by the triage nurse. Rationale for this decision will be recorded in the medical record." Levels defined were as follows: "Watch closely, Observe Closely, and Observation with one-to-one (1-to-1) contact at all times."

2. The medical record of Patient #8 was reviewed on 6/10/15 and revealed the patient presented to the facility's ED on 3/14/15 with a chief complaint of "Bad thoughts, onset yesterday, pt. states that she had feelings of wanting to hurt herself." Review of physician's note revealed the entry: "Patient presents to the emergency room today for wanting to run away and wanting to shoot herself." No documentation was found in the record indicating an assessment for, and/or initiation of, a Precaution level had been completed.

3. The above documentation was reviewed and discussed with the CNO on 6/10/15 at 12:20 p.m. at which time she concurred with the above findings.

Based on medical record review, observation, staff and patient interview it was determined the Registered Nurse (RN) failed to evaluate and address the nursing care needs for one (1) of one (1) patients interviewed related to nursing needs (Patient #1). This failed practice creates the potential for an adverse impact on the care and condition of all patients.

Findings are:

1. Review of the medical record for Patient #1 on 6/9/15 revealed the patient was admitted through the Emergency Department on 6/06/15. Review of the 6/7/15 History and Physical Examination revealed, in part: "Seventy-five (75) year-old female presented for shortness of breath and weakness. Patient was found down along side her bed too weak to get up, called for 911 to come and assist. When they arrived her oxygen saturation was 88% on room air, she was ash in color, patient's family states that she was disoriented and does not recognize any family members, she does have some baseline dementia but they stated this is much worse... Diagnosis: 1. Pneumonia 2. Hyponatremia."

Review of the 6/6/15 Nursing Admission Assessment, revealed RN # 1 documented the patient was not well hydrated and had not eaten for 2 days. The patient was noted to be 5 feet 2 inches tall and weight was recorded as 81 lbs. The RN also evaluated the patient as being high risk for falls.

Review of the patient intake since admission revealed nursing staff was recording the patient was consuming twenty-five (25) to fifty (50) percent of meals. The record reflected the patient was reweighed by nursing staff on 6/9/15 and the weight was recorded as ninety-five (95) pounds, reflecting a fourteen (14) pound weight gain since admission. The record lacked any nursing documentation related to the discrepancy in the patient's weights or physician referral related to patient's nutritional status or weight. The record reflected the patient was not receiving nutritional supplements and had not been referred to dietary for follow-up. The record also lacked documentation to reflect the patient was referred for a physical therapy evaluation related to the weakness and high fall risk.

Observation and interview with Patient #1 and her close friend was conducted at 11:10 a.m. on 6/9/15. The Acute Care Manager accompanied the surveyor for this observation and interview. The patient and friend explained that she lived alone but the friend came over and they cooked and ate meals together. They stated they had been friends for a number of years. When asked about the patient's nutritional status and diet at home, the friend stated the patient's normal weight was one hundred and twenty-five (125) pounds and her last weight at the doctor's office prior to admission was eighty-three (83) pounds. He stated she had lost a lot of weight in the last two (2) to three (3) months and become so weak she now needs help turning in the hospital bed. The patient stated she did not use a cane or assistive device at home as she has only recently become so weak. The friend stated the patient was drinking Ensure dietary supplements at home.

When asked about skin breakdown the friend said she now had breakdown over her backbone which was being treated by nursing staff with a cream medicine and a dressing. The Acute Nursing Manager asked to look at the patient's skin. Her examination revealed broken areas of skin over the patient's backbone which were covered with cream and a large dressing. The patient's backside appeared quite bony with vertebrae visualized quite prominently through the patient's skin.

This case and record were reviewed with the Acute Care Manager at 11:40 a.m. She agreed the patient's skin breakdown was being treated by nursing staff but had not yet been referred to the physician for evaluation and orders. She acknowledged nursing interventions such as use of a specialty mattress or other positioning aides were not currently being utilized. The Acute Care Manager also agreed the nurse failed to identify and record the significant weight loss at admission and refer the patient for nutritional/dietary assessment and follow-up. She confirmed the patient was currently on a regular diet and was not receiving dietary supplements. She agreed the patient weight of ninety-five (95) pounds recorded on 6/9/15 was obviously an error and should have been followed up by nursing staff. She acknowledged the nursing admission assessment was not completed with all relevant and necessary information for planning nursing care.

Based on medical record review, observation, staff and patient interview it was determined the nurse failed to develop and keep a current nursing care plan for one (1) of (1) one inpatients interviewed related to nursing needs (Patient #1). This failed practice has the potential to adversely impact the care and condition of all patients.

Findings are:

1. Review of the medical record for Patient #1 on 6/9/15 revealed the patient was admitted through the Emergency Department on 6/6/15. Review of the 6/7/15 History and Physical Examination revealed, in part: "Seventy-five (75) year-old female presented ...for shortness of breath and weakness. Patient was found down along side her bed too weak to get up ... called for 911 to come and assist. When they arrived her oxygen saturation was Eighty-eight (88) percent on room air, she was ash in color, patient's family states that she was disoriented and does not recognize any family members, she does have some baseline dementia but they stated this is much worse...Diagnosis: 1. Pneumonia 2. Hyponatremia."

Review of the 6/6/15 Nursing Admission Assessment revealed Registered Nurse (RN)
#1 documented the patient was not well hydrated and had not eaten for two (2) days. The patient was noted to be five (5) feet two (2) inches tall and weight was recorded as eighty-one (81) pounds. The RN evaluated the patient as being high risk for falls.

Review of the patient intake since admission revealed nursing staff was recording the patient was consuming twenty-five (25) to fifty (50) percent of meals. The record reflected the patient was reweighed by nursing staff on 6/9/15 and the weight was recorded as ninety-five (95) pounds, reflecting a fourteen (14) pound weight gain since admission. The record lacked any nursing documentation related to the discrepancy in the patient's weights or physician referral related to patient's nutritional status or weight. The record reflected the patient was not receiving nutritional supplements and had not been referred to dietary for follow-up. The record also lacked documentation to reflect the patient was referred for physical therapy evaluation related to the weakness and high fall risk.

Observation and interview with Patient #1 and her close friend was conducted at 11:10 a.m. on 6/9/15. The Acute Care Manager accompanied the surveyor for this observation and interview. The patient and friend explained she lived alone but the friend came over and they cooked and ate meals together. They stated they had been friends for a number of years. When asked about the patient's nutritional status and diet at home, the friend stated the patient's normal weight was one hundred and twenty-five (125) pounds and her last weight at the doctor's office prior to admission was eighty-three (83) pounds. He stated she had lost a lot of weight in the last two (2) to three (3) months and become so weak she now needs help turning in the hospital bed. The patient stated she did not use a cane or assistive device at home as she has only recently become so weak. The friend stated the patient was drinking Ensure dietary supplements at home.

When asked about Patient #1's skin breakdown the friend said she now had breakdown over her backbone which was being treated by nursing staff with a cream medicine and a dressing. The Acute Nursing Manager asked to look at the patient's skin. Her examination revealed broken areas of skin over the patient's backbone which were covered with cream and a large dressing. The patient's backside appeared quite bony with vertebrae visualized quite prominently through the patient's skin.

Review of the patient's current Problem List and Nursing Plan of Care on 6/9/15 revealed the patient's weight loss and nutritional needs were not addressed by nursing. The Problem for Skin Integrity was not current as it reflected the goal was that patient wouldn't experience skin breakdown during the admission. The skin was observed to have broken down and the nurse failed to notify the physician and implement interventions to heal the skin and prevent further breakdown.

This case and record were reviewed with the Acute Care Manager at 11:40 a.m. She acknowledged the nursing staff failed to implement a care plan and initiate nursing interventions related to the patient's weight loss, nutritional needs and skin integrity care plans were not kept current.