HospitalInspections.org

Based on record review and interviews, the hospital failed to meet the Condition of Participation for Patient Rights as evidenced by:

Failing to ensure each patient was free from neglect and that neglect was reported to DHH (Department of Health and Hospitals) within 24 hours as required by state law for 1 of 5 sampled patients (#3). This resulted in Patient #3 being admitted with no wounds, being discharged with no assessment of wounds by the RN, and returning the same day to the emergency department (ED) with right leg echhymosis and his right foot cold, cyanotic, and without a pulse. Patient #3 had to be transferred to Hospital A where he underwent an emergent right above-knee amputation (see findings in tag A0145).

Based on record review and interviews, the hospital failed to ensure each patient was free from neglect and that neglect was reported to DHH (Department of Health and Hospitals) within 24 hours as required by state law for 1 of 5 sampled patients (#3). This resulted in Patient #3 being admitted with no wounds, being discharged with no assessment of wounds by the RN, and returning the same day to the emergency department (ED) with right leg echhymosis and his right foot cold, cyanotic, and without a pulse. Patient #3 had to be transferred to Hospital A where he underwent an emergent right above-knee amputation. Findings:

Review of Patient #3's medical record revealed he was an 88 year old male admitted on 05/02/12 with a diagnosis of acute appendicitis.

Review of Patient #3's "Emergency Department Physician Medical Record" documented by Physician S8 on 05/02/12 at 9:38pm revealed his skeletal exam "shows no significant abnormality; no traumatic". Further review revealed his diagnosis was abdominal pain and acute appendicitis.

Review of the "Emergency Department Nursing Medical Record" revealed Patient #3 arrived on 05/02/12 at 9:25pm, and his skin was dry and warm.

Review of Patient #3's "History And Physical" performed "5/3", with no documented evidence of the year and time the exam was performed, revealed Patient #3 had a past history of atrial fibrillation, coronary artery disease, hypertension, dementia, and gout. Further review revealed extremities was documented as "(symbol signifying no) edema, the impression was acute appendicitis and hypertension, and the plan was for an appendectomy and administration of Metoprolol (antihypertensive).

Review of Patient #3's "Admit Assessment - General" performed on 05/03/12 at 12:40am revealed his skin was warm and pink, no pressure ulcer present, and he had a dime size skin tear to left hand.

Review of Patient #3's "PACU (post anesthesia care unit) Record" dated 05/03/12 at 2:10pm revealed he had SCDs (sequential compression device) and TED (thromboembolytic device) hose applied in PACU.

Review of Patient #3's nursing documentation from 05/03/12 through 05/06/12 revealed his skin was warm and dry with no documented evidence of skin abnormality to the lower extremities.

Review of Patient #3's nursing assessment on 05/07/12 at 7:30am revealed his skin was warm and dry, turgor good, color good, no decubitus, and SCDs and TED hose in place.

Review of the Physical Therapy (PT) evaluation performed on 05/07/12 at 11:35am by PT S9 revealed Patient #3 was unable to tolerate passive range of motion to the right lower extremity secondary to pain, and there was no active range of motion noted. Further review revealed "c/o (complained of) pain w/ (with) wt (weight) bearing & any touch/mvt (movement) to RLE (right lower extremity). Reports pain from knee to foot. Noted discoloration to rt (right) toes, foot & heel with bunion pad to medial foot. Heel bows obtained & applied. Pt left with heel bows intact & bil (bilateral) feet floating on pillow. Nsg (nursing) notified...".

Review of LPN S16's assessment on 05/07/12 at 7:45pm revealed "nonpitting edema noted to bilat (bilateral) feet. Drsg (dressing) C/D/I (clean/dry/intact) to R (right) inner great toe. ... TEDs and SCDs intact".

Review of Patient #3's skin assessments after 05/07/12 at 7:45pm revealed the following:
05/07/12 at 8:00pm - skin warm and dry, turgor good, no decubitus, dressing to right inner great toe clean,dry, and intact, and scab noted to left heel;
05/08/12 at 7:10am - skin warn and dry, turgor good, dressing to right great toe clean, dry, and intact, and no decubitus;
05/08/12 at 5:44pm - dressing changed to right great toe by RN S14 with no documented evidence of an assessment and appearance of the wound;
05/08/12 at 7:45pm - bilateral SCDs and TEDs intact, bilateral feet are discolored, bandaid noted to right inner great toe clean, dry, and intact, skin tears noted to left heel and right foot; assessment by LPN S16 with no documented evidence that the RN was notified of the changes in the condition of Patient #3's skin;
05/09/12 at 8:30am - skin warm and dry, turgor good, right foot skin tear and right toe skin tear, left hand skin tear, SCDs and TED hose intact; no documented evidence of wound care provided to skin tears;
05/09/12 at 8:30pm - skin warm and dry, turgor good, color good, no decubitus, radial and pedal pulses present, no edema, extremities pink and warm, movable within patient's range of motion;
05/10/12 at 7:49am by RN S10 - TEDs and SCDs bilaterally and heel boots on, no decubitus, wound on right foot dressed.

Review of the entire medical record revealed no documented evidence of an assessment and description of the wound that was dressed to the right great toe, that any wounds were reported to the attending physician, and that wound care orders were obtained for Patient #3.

Review of the nursing notes documented by RN S10 on 05/10/12 at 11:45am revealed Patient #3 was discharged and taken by the van from the nursing home.

Review of Patient #3's "Emergency Department Physician Medical Record" documented by Physician S8 on 05/10/12 at 3:27pm revealed he was an 88 year old male who was discharged from Lane Regional Medical Center today after having an appendectomy. Further review revealed when Patient #3 returned to the nursing home, it was noted that his right leg/foot was cold and discolored, and he was returned to Lane Regional Medical Center for re-evaluation. Review of S8's physical examination of Patient #3 revealed his (#3) right leg had ecchymosis noted from just below the knee to the foot, the foot was cold with no pulse, and the foot was cyanotic. Further review revealed Patient #3's diagnosis was acute arterial insufficiency to the right lower extremity. Further review revealed on 05/10/12 at 4:01pm Physician S8 consulted with Physician S26 at Hospital A who requested that a heparin infusion be initiated and Patient #3 be transferred to Hospital A.

Review of the "Emergency Department Nursing Medical Record" revealed the following entry on 05/10/12 at 3:39pm by RN S11: "discoloration to rt (right) foot, all digits black. Dorsal aspect of rt foot with transparent appearance, yellow in color. Red streak 2 cm in width radiating from knee down to top of rt foot. No pulses palpable or with doppler to dorsal pedal or posterior tibial. Temp. (temperature) cold to the touch from tip of toes to midway up tibia. Lt (left) lower extremity warm to the touch, skin tone normal in color. Weak palpable DP (dorsal pedal) pulses noted. See photos attached to medical record".

Review of the "Imaging Report" of the ultrasound of the right arterial lower extremity performed and read on 05/10/12 at 5:13pm revealed the impression of "occlusion of in situ right fem pop (femoral popliteal) graft with no flow in the infragenicular vessels".

Review of Patient #3's "History & Physical" dictated on 05/10/12 at 8:02pm by Physician S26 at Hospital A revealed the following: History of Present Illness ... "We spoke to the emergency room physician who said the foot was ice cold as well as no function in the right foot in which he suspected embolic event from his atrial fibrillation; therefore, he was immediately put on IV (intravenous) heparin and sent to us for definitive care. ... Physical Examination... Vascular: Nonpalpable right lower extremity pulses. Plus 2 left femoral with +1 popliteal and pedal pulses. Musculoskeletal: The entire right lower extremity is cold to touch. The patient has no function of the right lower extremity. The right foot is mottled with skin blistering and the entire all 4 compartments of the right lower extremity are dead as well as the right foot. There is skin sloughing of the right foot and anterior calf. ... Plan Non--salvageable right lower extremity: Since this patient has non-salvageable right lower extremity and he does have altered mental status, this may be because of the dead tissue in the right lower extremity. Therefore we will perform an emergent right above-knee amputation...".

In a face-to-face interview on 05/24/12 at 1:25pm, PT S9 indicated that she did Patient #3's PT evaluation on 05/07/12. She further indicated that he had TED hose on, and she didn't remove them. She further indicated that she couldn't remember if his SCDs were on. S9 indicated Patient #3 was very sensitive to her touch when she moved the toe part of the TED hose on the right foot. She further indicated he had a bunion pad on the right inner big toe and discoloration to the top of the foot. S9 indicated she could see through the TED hose that there was discoloration to the right heel. She further indicated that she reported that he was sensitive to touch and her observations of the appearance of his right foot and heel to RN S14.

In a face-to-face interview on 05/24/12 at 1:35pm, RN S10 indicated that he had been employed at this hospital since March 2012. He further indicated he was the RN who discharged Patient #3 on 05/10/12. S10 indicated he performed a "focused assessment" based on Patient #3 having had an appendectomy. He further indicated he looked at the bandaids applied to Patient #3's abdomen, checked his bilateral radial and pedal pulses, and did not remove his TED hose. S10 indicated Patient #3 did not have a palpable right pedal pulse that he noticed. He further indicated that it was a busy day, which was not an excuse, but he didn't do anything related to the absent pedal pulse and did not assess his lower extremities. S10 indicated he assumed most patients needed a doppler to check for pedal pulses, but he didn't have time to get a doppler. He further indicated that he did not notice any discoloration to Patient #3's right foot. S10 indicated that he did not report the absence of a right pedal pulse to the physician or the charge nurse.

In a face-to-face interview on 05/24/12 at 2:00pm, RN S11 indicated that she was the RN working in the emergency department when Patient #3 returned on 05/10/12 after having been discharged earlier the same day. She further indicated Patient #3's toes on the right foot were black eschar, and the top of the foot was yellowed.

In a face-to-face interview on 05/24/12 at 2:15pm, Unit Director RN S12 indicated when she was notified by the emergency department (ED) that Patient #3 had returned, she went to observe his extremities. She further indicated that she brought 3 of the nurses who had cared for Patient #3 during his hospital stay with her, one of whom was RN S10. She further indicated that two of the 3 nurses told her that Patient #3's leg did not look like it did in the ED when they had cared for him on the 1st South unit. She further indicated that RN S10 told her that his (#3) leg looked like it did when he discharged him earlier that day.

In a face-to-face interview on 05/24/12 at 2:40pm, RN S13 indicated she cared for Patient #3 on the night shifts of 05/05/12, 05/06/12, and 05/09/12. She further indicated that she removed his TED hose on 05/06/12, and his legs were "a little discolored", blancheable, and pulses present with a skin tear to the front of the right leg. S13 could offer no explanation for not documenting the skin tear to the front of the right leg. When asked what she meant by "a little discolored", S13 indicated it was mottled, dark but not gray, and a little transparent but could not describe the color. She further indicated that both legs looked the same. S13 indicated that she did not remove the TED hose on 05/09/12 and did not assess the lower extremities. She further indicated she felt for pedal pulses, and both were present. S13 indicated Patient #3 had SCDs on all three shifts that she worked.

In a face-to-face interview on 05/24/12 at 3:00pm, RN S14 indicated that she cared for Patient #3 on 05/07/12 and 05/08/12. She further indicated that although her documentation revealed that Patient #3 did not have SCDs and TED hose on, he did have them in place. She could offer no explanation for her documentation not matching what she observed. S14 indicated that on 05/07/12 she pulled the TED hose half-way down, got called from the room, and returned to pull the hose back up but never removed them. She further indicated she changed the dressing to the right great toe, and it looked like a skin tear, corn, or scrape. She further indicated that she did not check for wound care orders and just assumed there were orders. S14 indicated she used Saf-klenz, Saf-gel, and applied a bandaid. S14 indicated PT S9 reported that Patient #3 had softness noted to his heel, and she (S9) applied heel bows. She further indicated it was at this time that she went to assess the patient and got called from the room. After review of the record, RN S14 indicated she remembered the heel bows being reported but didn't remember anything about his pain. She further indicated she remembered Patient #3 having discoloration to the leg, but she didn't remember if she observed it or if it was reported to her. S14 indicated when she pulled the TED hose half-way back, she saw redness along the shin of the right leg.

In a face-to-face interview on 05/25/12 at 7:55am, Physician S8 indicated he was the emergency physician who saw Patient #3 on his initial visit with acute appendicitis and when he returned on 05/10/12 after having been discharged earlier the same day. He further indicated there was no specific skin abnormality at the time of his first visit on 05/02/12. S8 indicated at the time of the second visit on 05/10/12, Patient #3's right lower extremity was discolored and very little blood flow. He indicated that the ultrasound performed during this visit revealed that he had a previous graft that was occluded and no flow to the right lower leg. When asked if the SCD or TED hose could have contributed to the condition of the right leg, S8 indicated he couldn't answer the question, since he was not a vascular surgeon. When asked if an earlier assessment of the changes to Patient #3's right leg could have prevented the need for amputation, S8 indicated it was only his opinion that yes it could, but this answer was not based on an educated standpoint of being a vascular surgeon.

In a face-to-face interview on 05/25/12 at 8:30am, Physician S15 indicated that he was Patient #3's attending physician. He further indicated there was no gross abnormality to Patient #3's bilateral feet and legs when he was admitted on 05/02/12. When asked if the SCD or TED hose could have contributed to the circulatory problem of the right leg, S15 answered "not really. S15 indicated he checked for swelling of the feet during his visits, but he didn't open the SCDs or lower the TED hose to see his legs. He further indicated the staff did not report any changes to the lower extremities to him. When asked if an earlier assessment of the changes to Patient #3's right leg could have prevented the need for amputation, S15 indicated that if it was detected in time it could be prevented, but he didn't know how his surgery (appendectomy) had affected the thromboembolytics. He further indicated if it was detected in time, thromboembolytics could have been prescribed to dislodge the clot.

In a face-to-face interview on 05/25/12 at 9:40am, LPN S16 indicated that she was working in the ED when Patient #3 was first brought in with acute appendicitis. She further indicated his legs and feet were a little discolored with purplish bruising. S16 confirmed that she did not document this observation. She indicated that cared for Patient #3 on the unit on 05/07/12 on the night shift. S16 indicated he had bruising/discoloration to bilateral lower extremities. She further indicated she pulled the TED hose down but didn't remove them. She further indicated Patient #3 had bilateral pedal pulses, and the extremities were warm. She further indicated he had a bandage to the right great toe which was something he came in with from the nursing home. S16 indicated on 05/08/12 on the night shift Patient #3 had SCDs and TED hose on. She further indicated that she lowered the the TED hose, and he had a bandaid to the right great toe with a new skin tear to the heel. S16 indicated he had pulses to both feet, and both lower extremities were warm. She further indicated there was what looked like bruising, the same that she had observed on his presence in the ED on 05/02/12. She further indicated that it was not anything that was reportable.

In a face-to-face interview on 05/24/12 at 9:15am, Director of Nursing (DON) S2 indicated that Unit Director RN S12 interviewed all the nurses who were involved in Patient #3's care and began some education. S2 further indicated that they realized they needed a policy for wound assessments and were in the process of formulating one. She further indicated no specific changes had been made to prevent a reoccurrence as of this time other than a monitoring tool that the clinical leader, diabetes educator, and unit manager were using to assess patients with wounds (see interview at 2:30pm with DON S2 that describes this tool).

In a face-to-face interview on 05/24/12 at 2:15pm, Unit Director RN S12 indicated she was in the process of investigating Patient #3's stay. She indicated when she was notified by the emergency department (ED) that Patient #3 had returned, she went to observe his extremities. She further indicated that she brought 3 of the nurses who had cared for Patient #3 during his hospital stay with her, one of whom was RN S10. She further indicated that two of the 3 nurses told her that Patient #3's leg did not look like it did in the ED when they had cared for him on the 1st South unit. She further indicated that RN S10 told her that his (#3) leg looked like it did when he discharged him earlier that day. S12 indicated that she met with various nurses but had no documentation of the dates and what was discussed. In the same interview DON S2 indicated she spoke with an employee at the nursing home, but she didn't document any of her conversation

In a face-to-face interview on 05/24/12 at 2:30pm, DON S2 indicated she didn't "know if she would say neglect" when asked about neglect of Patient #3. She further indicated that she did not report the occurrence to DHH, because she didn't see it as neglect. DON S2 indicated a monitoring tool had been initiated since the occurrence whereby the clinical leader, diabetes educator, and unit manager would assess all patients who were identified with wounds. When told by the surveyor that such a tool would not have prevented the occurrence with Patient #3 since he had not been identified as having a wound, S2 indicated she would have to add TED hose as part of the screening to the tool.

Review of the hospital policy titled "Patient Rights", number 16.01, revised 08/11, and presented by Performance Improvement Officer S1 as a current policy, revealed, in part, "...Patients have the right to be free form (from) mental, physical, sexual and verbal abuse, neglect, and exploitation...".

Review of the hospital policy titled "Abuse - Inpatient", number 1.01.03, reviewed 03/12, and presented by Performance Improvement Officer S1 as a current policy, revealed, in part, "...Neglect: For the purpose of this requirement, neglect is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness ... Identification A. The hospital creates and maintains a proactive approach to identify events and occurrences that may be constituted or contribute to abuse or neglect. B. Any occurrences that may contribute to abuse or neglect will be investigated to implement appropriate interventions to prevent the abuse or neglect from occurring. ... Investigation A. The hospital will ensure, in a timely and thorough manner, an objective investigation of any allegations of abuse, neglect, or harassment. 7. report/Response A. The hospital will assure that any incidents of abuse, neglect or harassment are reported and analyzed and that the appropriate corrective, remedial or disciplinary actions occur in accordance with applicable Local, State or Federal Law".

Review of the Louisiana Revised Statute 40:2009.20 revealed, in part, "?2009.20. Duty to make complaints; penalty; immunity
A. As used in this Section, the following terms shall mean:
(1) "Abuse" is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered.
(2) "Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being.
B.(1) Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, home- and community-based service provider employee or worker, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct caregiver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report...".

Based on record review and interview, the hospital failed to ensure each patient who was restrained was monitored by trained staff at least every 2 to 3 hours as required by hospital policy for 1 of 1 patients reviewed with restraints from a total sample of 5 patients (#3). Findings:

Review of Patient #3's medical record revealed he was an 88 year old male admitted on 05/02/12 with a diagnosis of acute appendicitis.

Review of Patient #3's "Physician's Orders Restraint Orders" revealed he had orders for restraints on 05/03/12, 05/04/12, 05/05/12, 05/06/12, 05/07/12, 05/08/12, 05/09/12, and 05/10/12.

Review of Patient #3's every 2 hour restraint assessment documentation revealed no documented evidence Patient #3 was assessed while in restraints on 05/07/12 after 7:30am until 8:00pm (12 hours 30 minutes without assessment). Further review revealed no documented evidence Patient #3 was assessed while in restraints on 05/08/12 from 12:00pm until 8:00pm (8 hours without assessment).

In a face-to-face interview on 05/24/12 at 4:05pm, Director of Nursing S2 indicated Unit Director RN S12 reviewed Patient #3's medical record and could find no documentation of restraint assessments for the times listed above on 05/07/12 and 05/08/12.

Review of the hospital policy titled "Use Of Restraints For Non-Violent/Non Self-Destructive (NV/NSD) Behavior", number 18.04, revised 01/12, and presented by Performance Improvement Officer S1 as a current policy revealed, in part, "...5. A trained and competent RN (registered nurse), PA (physician assistant), or NP (nurse practitioner) shall assess the individual prior to the initiation of restraints and an RN, LPN (licensed practical nurse), PA, or NP shall assess the individual a minimum of every 2-3 hours while the patient remains in restraints and document thereafter...".

Based on record review and interview, the hospital failed to focus performance improvement activities on high-risk, high-volume, or problem prone areas that affect health outcomes. The hospital failed to track, trend, and analyze skin and wound assessments on the 1st South unit that were identified as a high-volume, problem prone area for the unit. The hospital failed to develop a system for monitoring patients who returned to the emergency department the same day following discharge and requiring transfer for treatment to another facility. This resulted in Patient #3 being admitted with no wounds, being discharged with no assessment of wounds by the RN, and returning the same day to the emergency department (ED) with right leg echhymosis and his right foot cold, cyanotic, and without a pulse. Patient #3 had to be transferred to Hospital A where he underwent an emergent right above-knee amputation. Findings:

Review of Patient #3's medical record revealed he was an 88 year old male admitted on 05/02/12 with a diagnosis of acute appendicitis. Review of his "Emergency Department Physician Medical Record" documented by Physician S8 on 05/02/12 at 9:38pm revealed his skeletal exam "shows no significant abnormality; no traumatic". Further review revealed his diagnosis was abdominal pain and acute appendicitis.

Review of the "Emergency Department Nursing Medical Record" revealed Patient #3 arrived on 05/02/12 at 9:25pm, and his skin was dry and warm.

Review of Patient #3's "History And Physical" performed "5/3", with no documented evidence of the year and time the exam was performed, revealed Patient #3 had a past history of atrial fibrillation, coronary artery disease, hypertension, dementia, and gout. Further review revealed extremities was documented as "(symbol signifying no) edema, the impression was acute appendicitis and hypertension, and the plan was for an appendectomy and administration of Metoprolol (antihypertensive).

Review of Patient #3's "Admit Assessment - General" performed on 05/03/12 at 12:40am revealed his skin was warm and pink, no pressure ulcer present, and he had a dime size skin tear to left hand. Review of his "PACU (post anesthesia care unit) Record" dated 05/03/12 at 2:10pm revealed he had SCDs (sequential compression device) and TED (thromboembolytic device) hose applied in PACU.

Review of Patient #3's nursing documentation from 05/03/12 through 05/06/12 revealed his skin was warm and dry with no documented evidence of skin abnormality to the lower extremities.

Review of Patient #3's nursing assessment on 05/07/12 at 7:30am revealed his skin was warm and dry, turgor good, color good, no decubitus, and SCDs and TED hose in place.

Review of the Physical Therapy (PT) evaluation performed on 05/07/12 at 11:35am by PT S9 revealed Patient #3 was unable to tolerate passive range of motion to the right lower extremity secondary to pain, and there was no active range of motion noted. Further review revealed "c/o (complained of) pain w/ (with) wt (weight) bearing & any touch/mvt (movement) to RLE (right lower extremity). Reports pain from knee to foot. Noted discoloration to rt (right) toes, foot & heel with bunion pad to medial foot. Heel bows obtained & applied. Pt left with heel bows intact & bil (bilateral) feet floating on pillow. Nsg (nursing) notified...".

Review of LPN S16's assessment on 05/07/12 at 7:45pm revealed "nonpitting edema noted to bilat (bilateral) feet. Drsg (dressing) C/D/I (clean/dry/intact) to R (right) inner great toe. ... TEDs and SCDs intact".

Review of Patient #3's skin assessments after 05/07/12 at 7:45pm revealed the following:
05/07/12 at 8:00pm - skin warm and dry, turgor good, no decubitus, dressing to right inner great toe clean,dry, and intact, and scab noted to left heel;
05/08/12 at 7:10am - skin warn and dry, turgor good, dressing to right great toe clean, dry, and intact, and no decubitus;
05/08/12 at 5:44pm - dressing changed to right great toe by RN S14 with no documented evidence of an assessment and appearance of the wound;
05/08/12 at 7:45pm - bilateral SCDs and TEDs intact, bilateral feet are discolored, bandaid noted to right inner great toe clean, dry, and intact, skin tears noted to left heel and right foot; assessment by LPN S16 with no documented evidence that the RN was notified of the changes in the condition of Patient #3's skin;
05/09/12 at 8:30am - skin warm and dry, turgor good, right foot skin tear and right toe skin tear, left hand skin tear, SCDs and TED hose intact; no documented evidence of wound care provided to skin tears;
05/09/12 at 8:30pm - skin warm and dry, turgor good, color good, no decubitus, radial and pedal pulses present, no edema, extremities pink and warm, movable within patient's range of motion;
05/10/12 at 7:49am by RN S10 - TEDs and SCDs bilaterally and heel boots on, no decubitus, wound on right foot dressed.

Review of the entire medical record revealed no documented evidence of an assessment and description of the wound that was dressed to the right great toe, that any wounds were reported to the attending physician, and that wound care orders were obtained for Patient #3.

Review of the nursing notes documented by RN S10 on 05/10/12 at 11:45am revealed Patient #3 was discharged and taken by the van from the nursing home.

Review of Patient #3's "Emergency Department Physician Medical Record" documented by Physician S8 on 05/10/12 at 3:27pm revealed he was an 88 year old male who was discharged from Lane Regional Medical Center today after having an appendectomy. Further review revealed when Patient #3 returned to the nursing home, it was noted that his right leg/foot was cold and discolored, and he was returned to Lane Regional Medical Center for re-evaluation. Review of S8's physical examination of Patient #3 revealed his (#3) right leg had ecchymosis noted from just below the knee to the foot, the foot was cold with no pulse, and the foot was cyanotic. Further review revealed Patient #3's diagnosis was acute arterial insufficiency to the right lower extremity. Further review revealed on 05/10/12 at 4:01pm Physician S8 consulted with Physician S26 at Hospital A who requested that a heparin infusion be initiated and Patient #3 be transferred to Hospital A.

Review of the "Emergency Department Nursing Medical Record" revealed the following entry on 05/10/12 at 3:39pm by RN S11: "discoloration to rt (right) foot, all digits black. Dorsal aspect of rt foot with transparent appearance, yellow in color. Red streak 2 cm in width radiating from knee down to top of rt foot. No pulses palpable or with doppler to dorsal pedal or posterior tibial. Temp. (temperature) cold to the touch from tip of toes to midway up tibia. Lt (left) lower extremity warm to the touch, skin tone normal in color. Weak palpable DP (dorsal pedal) pulses noted. See photos attached to medical record".

Review of the "Imaging Report" of the ultrasound of the right arterial lower extremity performed and read on 05/10/12 at 5:13pm revealed the impression of "occlusion of in situ right fem pop (femoral popliteal) graft with no flow in the infragenicular vessels".

Review of Patient #3's "History & Physical" dictated on 05/10/12 at 8:02pm by Physician S26 at Hospital A revealed the following: History of Present Illness ... "We spoke to the emergency room physician who said the foot was ice cold as well as no function in the right foot in which he suspected embolic event from his atrial fibrillation; therefore, he was immediately put on IV (intravenous) heparin and sent to us for definitive care. ... Physical Examination... Vascular: Nonpalpable right lower extremity pulses. Plus 2 left femoral with +1 popliteal and pedal pulses. Musculoskeletal: The entire right lower extremity is cold to touch. The patient has no function of the right lower extremity. The right foot is mottled with skin blistering and the entire all 4 compartments of the right lower extremity are dead as well as the right foot. There is skin sloughing of the right foot and anterior calf. ... Plan Non--salvageable right lower extremity: Since this patient has non-salvageable right lower extremity and he does have altered mental status, this may be because of the dead tissue in the right lower extremity. Therefore we will perform an emergent right above-knee amputation...".

In a face-to-face interview on 05/25/12 at 9:25am, Unit Director RN S12 indicated that she was the manager for 1st South, the unit where Patient #3 received his care. She further indicated that each nursing department was responsible for their quality improvement indicators. S12 presented the "1 South Quality Indicators 2012" which revealed the indicators being tracked were as follows: 1) patient will be satisfied with care provided; 2) post coronary catheterization patients will be free of complications; 3) daily weights were completed as ordered; 4) documentation of weight gain or loss of 3 pounds or greater; 5) IVs (intravenous lines) less than 96 hours; 6) restraints orders were signed; and 7) pediatric IV therapy. S12 confirmed her unit was not monitoring wound or skin assessments monthly. S12 indicated quarterly a team of nurses including wound care nurses assessed every inpatient to identify wounds as part of the National Database of Nursing Quality Indicators. When asked if wounds on her unit were of a high volume and could be problem-prone, S12 answered yes. She indicated that monitoring for wounds was probably something that they should be monitoring more often than quarterly.

In a face-to-face interview on 05/25/12 at 9:25am (during the same interview with S12), Director of Nursing S2 indicated the hospital monitors discharges and readmissions, but they do not look at discharge and same day return to the emergency department.

In a face-to-face interview on 05/25/12 at 11:20am, Performance Improvement Officer S1 indicated she didn't see that high-volume, problem-prone areas were used to select quality indicators. She further indicated that she knew that's what they were doing, but she must have taken that section out when she revised the policy.

Review of the hospital's "Performance Improvement Plan", number 2.01, revised 03/09, and presented by Performance Improvement Officer S1 as current, revealed, in part, "...Each Department Manager will be responsible for conducting department meetings in which the department as a whole identifies areas for improvement within the department which would improve the overall patient outcome in the chosen priority areas for review. ... Each department will have a written Performance Improvement Plan which describes the methods to be used in performing Performance Improvement activities, delineates staff responsibilities for accomplishing tasks in a timely fashion, establishes the scope of care and services, and sets priorities for review. ... Each department will pick at least 2 dashboard indicators...". Review of the entire plan revealed no documented evidence that the hospital used high-volume, high-risk, problem-prone areas that affect health outcomes to develop quality indicators.

Based on record review and interviews, the hospital failed to meet the Condition of Participation for Nursing Services as evidenced by:

Failing to have a system in place for the assessment of wounds that included the measurement, staging, and the interval at which wounds had to be reassessed by the RN. This resulted in the RN failing to accurately assess the patient's skin integrity and wounds, notify the physician of the presence of wounds, obtain physician orders for the care of wounds, and perform wound care for 5 of 5 sampled patients (#1, #2, #3, #4, #5). This resulted in Patient #3 being admitted with no wounds, being discharged with no assessment of wounds by the RN, and returning the same day to the emergency department (ED) with right leg echhymosis and his right foot cold, cyanotic, and without a pulse. Patient #3 had to be transferred to Hospital A where he underwent an emergent right above-knee amputation (see findings in tag A0395).

Based on observation, record review, and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care of each patient. 1) The hospital failed to have a system in place for the assessment of wounds that included the measurement, staging, and the interval at which wounds had to be reassessed by the RN. This resulted in the RN failing to accurately assess the patient's skin integrity and wounds, notify the physician of the presence of wounds, obtain physician orders for the care of wounds, and perform wound care for 5 of 5 sampled patients (#1, #2, #3, #4, #5). This resulted in Patient #3 being admitted with no wounds, being discharged with no assessment of wounds by the RN, and returning the same day to the emergency department (ED) with right leg echhymosis and his right foot cold, cyanotic, and without a pulse. Patient #3 had to be transferred to Hospital A where he underwent an emergent right above-knee amputation. 2) The RN failed to ensure that isolation precautions were implemented for 1 of 2 observations of wound assessments performed during the survey from a total of 5 sampled patients (#2). 3) The RN failed to assess patients' change in condition related to blood sugar, blood pressure, weight, and urinary output for 2 of 5 sampled patients (#1, #5). 4) The RN failed to clarify telemetry orders to verify individualized alarm settings for 3 of 3 patients reviewed with orders for telemetry from a total of 5 sampled patients (#1, #2, #4). 5) The RN failed to assess the patient's vital signs according to hospital policy during and after blood administration for 2 of 3 patients reviewed who received blood from a total of 5 sampled patients (#1, #2). Findings:

1) The hospital failed to have a system in place for the assessment of wounds that included the measurement, staging, and the interval at which wounds had to be reassessed by the RN. This resulted in the RN failing to accurately assess the patient's skin integrity and wounds, notify the physician of the presence of wounds, obtain physician orders for the care of wounds, and perform wound care:

In a face-to-face interview on 05/24/12 at 9:15am, Director of Nursing (DON) S2 indicated the hospital did not have a policy for wound care and the assessment of wounds that included the frequency of assessment, staging, and measuring of wounds and the nurse credentials required to perform wound assessments. She further indicated the only policy related to wounds was the policy for wound photographs and wound screening by the wound care team based on answers given by the patient during the initial assessment.

Patient #1
Review of Patient #1's medical record revealed he was a 71 year old male admitted on 05/13/12 with diagnoses of CHF (congestive heart failure) and Hypoxemia. Review of the "History And Physical" (H&P) written on 05/14/12 at 8:00am by Physician S15 revealed Patient #1 had bilateral below the knee amputations with "dry, shallow ulcer both stump". Further review revealed diagnoses of Hypertension, Diabetes Mellitus, and Urinary Tract Infection. Review of the consultation report of Physician S17 revealed Patient #1 had a "small stage II ulcer on the right stump which is clean...would just clean this and apply SAF-Gel daily and put a pillow under it to keep him from having pressure. His sacral area looks satisfactory, though is somewhat dry. Would just use daily cleansing and use Aloe Vesta on his lower back and also on his left stump...".

Review of Patient #1's "Physician's Orders" dated 05/14/12 at 8:45am revealed the following wound care orders: "1. (Right) BKA (below knee amputation) stump - cleanse. Apply Saf-gel. Cover with barrier dsg (dressing). (Change) daily. ... 3. (Left) BKA and sacral regions - no open wounds. Apply Aloe Vesta ointment daily and prn (as needed)...".

Review of Patient #1's "Admit Assessment - General" performed on 05/13/12 at 1742 (5:42pm) by RN S18 revealed the skin was cool and brown. Further review revealed wounds were noted to the right stump and sacrum, the left stump was dry and scaly, pictures were placed on the chart, and the patient did have a decubitus. Further review revealed no documented evidence of an assessment of the wounds to the right stump and sacrum that included the stage and measurements of the wound. Review of the photographs of the wounds revealed no documented evidence of the date the photograph was taken and the stage of the wound as required by hospital policy. Further review revealed no documented evidence of a completed skin assessment flowsheet attached to the photos as required by hospital policy.

Review of the "Skin Assessment Flowsheet" and "List Patient Notes" for Patient #1 revealed the following skin/wound assessments:
05/14/12 at 8:00am by RN S19 - "1 inch by 1 inch on R (right) stump. Area id escharred...";
05/15/12 at 7:45am by RN S19 - "wound to the R stump is 1 inch by 1 inch and is escharred";
05/19/12 at 9:45am by RN S20 - "R BKA stmp (stump) Width 0.5 cm (centimeters), Length 0.5 cm, Depth (left blank), Tunneling NA (not applicable), Undermining NA, Staging II, Periwound Tissue Intact, Drainage Type Serosang (serosanguinous), Tissue Type: Granulation Y (yes), Epithelialization Y, Slough N (no), Eschar N, Dressing Saturation Small, Odor None, Comments: Right BKA stump cleansed... Aloe Vesta applied to left BKA and sacrum...";
05/20/12 at 7:45am by RN S21 - "R BKA stmp Width 0.5 cm, Length 0.5 cm, Depth (left blank), Tunneling NA, Undermining NA, Staging II, Periwound Tissue Intact, Drainage Type Serosang, Tissue Type: Granulation Y, Epithelialization Y, Slough N, Eschar N, Dressing Saturation Small, Odor None, Comments: Right BKA stump cleansed... Aloe Vesta applied to left BKA and sacrum...";
05/20/12 at 2015 (8:15pm) by RN S22 - Right BKA stump cleansed... Aloe Vesta applied to left BKA and sacrum...";
05/20/12 at 7:45am by RN S21 - "R BKA stmp Width 0.5 cm, Length 0.5 cm, Depth (left blank), Tunneling NA, Undermining NA, Staging II, Periwound Tissue Intact, Drainage Type Serosang, Tissue Type: Granulation Y, Epithelialization Y, Slough N, Eschar N, Dressing Saturation Small, Odor None, Comments: Dsg to R stump C/D/I (clean/dry/intact);
05/22/12 at 9:20am by RN S14 - "wound care preformed (performed) to the right stump, drainage noted, no foul odor... To the buttocks area, pt (patient) has a spilt (split) in between checks (cheeks) which I changes this AM and on the side he has a skin tear about the size of 1/2 dollar...". There was no documented evidence of the measurement of the new wounds noted to the buttocks area or that the physician was notified to obtain wound care orders.

Review of Patient #1's medical record revealed no documented evidence of photographs of his wounds taken since 05/13/12. Further review revealed no documented evidence he received wound care on 05/18/12.

Observation on 05/22/12 at 12:35pm of Patient #1's skin with Clinical Nurse Leader RN S5 and RN S14 present revealed stage II pressure ulcers to the right stump, sacrum, and buttocks. When asked to measure the wounds, S5 and S14 began to give approximate measurements by viewing the wounds and not actually measuring with a measuring device. When asked to measure with a ruler, S5 and S14 obtained the following measurements:
Right stump - circular wound to right below the knee amputation 3.5 cm wide by 4.5 cm long draining serosanguinous drainage;
Left below the knee amputation site healed without a break in skin;
Sacrum - Stage II 3 cm long by 1 cm wide at the top of the wound and 2 cm wide at the bottom of the wound;
Left buttocks - Stage II 4 cm long by 2 cm wide at the top of the wound and 4.5 cm wide at the bottom of the wound.

In a face-to-face interview on 05/22/12 at 12:40pm, Clinical Nurse Leader RN S5 confirmed the wound measurements to the right stump were larger than what was documented on 05/20/12.

In a face-to-face interview on 05/22/12 at 12:40pm (during same interview with S5), RN S14 confirmed that she did not report the new wounds to Patient #1's sacrum and buttocks to the physician.

Patient #2
Review of Patient #2's medical record revealed she was a 68 year old female admitted on 05/18/12 at 2331 (11:31pm) with diagnoses of Pneumonia, Urinary Tract Infection, and Deconditioned. Review of the H&P performed 05/19/12 revealed Patient #2's past medical history included seizures, deep vein thrombosis and currently on Coumadin, chronic malnutrition, and recurrent anemia secondary to chronic malnutrition.

Review of Patient #2's "Admit Assessment - General" documented by RN S 23 on 05/18/12 at 11:31pm revealed her skin was warm and dry and pale in color. Further review revealed she had a Stage II decibitus to the right buttock measuring 0.2 cm wide by 0.2 cm long with no tunneling and no undermining. Further review revealed the periwound tissue was intact, there was no drainage, no odor, and blanchable redness to the periwound. Further review revealed there was a Stage II pressure ulcer to the right heel measuring 0.2 cm wide by 0.4 cm long with no tunneling and no undermining. Further review revealed the periwound tissue was "callus", and there was no drainage and no odor. There was no documented evidence that the physician was notified of the presence of pressure ulcers and wound care orders obtained at the time of admit. Further review of the medical record revealed two wound pictures with no documented evidence of the date the wounds were photographed, the location of the wounds, and the signature of the nurse who photographed the wounds and placed them in the medical record. Further review revealed no documented evidence of a completed skin assessment flowsheet attached to the photos as required by hospital policy.

Review of Patient #2's "Physician's Orders" revealed an order dated 05/19/12 at 9:50am for "wound care & (and) prevention to buttocks". There was no documented evidence of the specific wound care orders to be implemented to the buttocks and no orders for wound care to the right heel.

Review of the "Consultation" performed by Physician S17 on 05/21/12 at 9:28am revealed "on examination of her sacral region she had a stage I to II small area along the coccygeal region. On both feet in the heels she has some stage I changes...". Further review revealed no documented evidence of the measurements of the wounds to the sacral region and both heels.

Review of the "Physician's Orders" revealed a verbal order was received from Physician S17 for wound care including "cleanse sacral ulcer then apply Aloe Vesta and border dressing daily, Aloe Vesta to both heels, cradle boots to both feet". There was no documented evidence of what was to be used to cleanse the sacral area, and there was no documented evidence of a clarification order.

Review of the "Skin Assessment Flowsheet" documented by LPN (licensed practical nurse) S7 on 05/22/12 at 7:30am revealed Patient #2 had a Stage II decibitus to the right buttock measuring 0.2 cm wide by 0.2 cm long with no tunneling and no undermining. Further review revealed the periwound tissue was intact, and there was no drainage and no odor. Further review revealed there was a Stage II pressure ulcer to the right heel measuring 0.2 cm wide by 0.4 cm long with no tunneling and no undermining. Further review revealed the periwound tissue was "callus", and there was no drainage and no odor.

Observation of Patient #2's wounds on 05/22/12 at 1:35pm with LPN S7 and Clinical Nurse Leader RN S5 present revealed the following measurements performed by LPN S7: Stage II sacral decubitus 0.5 cm wide by 0.5 cm long; bilateral heels reddened with the right heel with scaly skin and no breakdown of skin noted to either heel.

In a face-to-face interview on 05/22/12 at 1:35pm, LPN S7 and Clinical Nurse Leader RN S5 could offer no explanation for the difference in measurement and appearance that was documented earlier by LPN S7.

Patient #3
Review of Patient #3's medical record revealed he was an 88 year old male admitted on 05/02/12 with a diagnosis of acute appendicitis.

Review of Patient #3's "Emergency Department Physician Medical Record" documented by Physician S8 on 05/02/12 at 9:38pm revealed his skeletal exam "shows no significant abnormality; no traumatic". Further review revealed his diagnosis was abdominal pain and acute appendicitis.

Review of the "Emergency Department Nursing Medical Record" revealed Patient #3 arrived on 05/02/12 at 9:25pm, and his skin was dry and warm.

Review of Patient #3's "History And Physical" performed "5/3", with no documented evidence of the year and time the exam was performed, revealed Patient #3 had a past history of atrial fibrillation, coronary artery disease, hypertension, dementia, and gout. Further review revealed extremities was documented as "(symbol signifying no) edema, the impression was acute appendicitis and hypertension, and the plan was for an appendectomy and administration of Metoprolol (antihypertensive).

Review of Patient #3's "Admit Assessment - General" performed on 05/03/12 at 12:40am revealed his skin was warm and pink, no pressure ulcer present, and he had a dime size skin tear to left hand.

Review of Patient #3's "PACU (post anesthesia care unit) Record" dated 05/03/12 at 2:10pm revealed he had SCDs (sequential compression device) and TED (thromboembolytic device) hose applied in PACU.

Review of Patient #3's nursing documentation from 05/03/12 through 05/06/12 revealed his skin was warm and dry with no documented evidence of skin abnormality to the lower extremities.

Review of Patient #3's nursing assessment on 05/07/12 at 7:30am revealed his skin was warm and dry, turgor good, color good, no decubitus, and SCDs and TED hose in place.

Review of the Physical Therapy (PT) evaluation performed on 05/07/12 at 11:35am by PT S9 revealed Patient #3 was unable to tolerate passive range of motion to the right lower extremity secondary to pain, and there was no active range of motion noted. Further review revealed "c/o (complained of) pain w/ (with) wt (weight) bearing & any touch/mvt (movement) to RLE (right lower extremity). Reports pain from knee to foot. Noted discoloration to rt (right) toes, foot & heel with bunion pad to medial foot. Heel bows obtained & applied. Pt left with heel bows intact & bil (bilateral) feet floating on pillow. Nsg (nursing) notified...".

Review of LPN S16's assessment on 05/07/12 at 7:45pm revealed "nonpitting edema noted to bilat (bilateral) feet. Drsg (dressing) C/D/I (clean/dry/intact) to R (right) inner great toe. ... TEDs and SCDs intact".

Review of Patient #3's skin assessments after 05/07/12 at 7:45pm revealed the following:
05/07/12 at 8:00pm - skin warm and dry, turgor good, no decubitus, dressing to right inner great toe clean,dry, and intact, and scab noted to left heel;
05/08/12 at 7:10am - skin warn and dry, turgor good, dressing to right great toe clean, dry, and intact, and no decubitus;
05/08/12 at 5:44pm - dressing changed to right great toe by RN S14 with no documented evidence of an assessment and appearance of the wound;
05/08/12 at 7:45pm - bilateral SCDs and TEDs intact, bilateral feet are discolored, bandaid noted to right inner great toe clean, dry, and intact, skin tears noted to left heel and right foot; assessment by LPN S16 with no documented evidence that the RN was notified of the changes in the condition of Patient #3's skin;
05/09/12 at 8:30am - skin warm and dry, turgor good, right foot skin tear and right toe skin tear, left hand skin tear, SCDs and TED hose intact; no documented evidence of wound care provided to skin tears;
05/09/12 at 8:30pm - skin warm and dry, turgor good, color good, no decubitus, radial and pedal pulses present, no edema, extremities pink and warm, movable within patient's range of motion;
05/10/12 at 7:49am by RN S10 - TEDs and SCDs bilaterally and heel boots on, no decubitus, wound on right foot dressed.

Review of the entire medical record revealed no documented evidence of an assessment and description of the wound that was dressed to the right great toe, that any wounds were reported to the attending physician, and that wound care orders were obtained for Patient #3.

Review of the nursing notes documented by RN S10 on 05/10/12 at 11:45am revealed Patient #3 was discharged and taken by the van from the nursing home.

Review of Patient #3's "Emergency Department Physician Medical Record" documented by Physician S8 on 05/10/12 at 3:27pm revealed he was an 88 year old male who was discharged from Lane Regional Medical Center today after having an appendectomy. Further review revealed when Patient #3 returned to the nursing home, it was noted that his right leg/foot was cold and discolored, and he was returned to Lane Regional Medical Center for re-evaluation. Review of S8's physical examination of Patient #3 revealed his (#3) right leg had ecchymosis noted from just below the knee to the foot, the foot was cold with no pulse, and the foot was cyanotic. Further review revealed Patient #3's diagnosis was acute arterial insufficiency to the right lower extremity. Further review revealed on 05/10/12 at 4:01pm Physician S8 consulted with Physician S26 at Hospital A who requested that a heparin infusion be initiated and Patient #3 be transferred to Hospital A.

Review of the "Emergency Department Nursing Medical Record" revealed the following entry on 05/10/12 at 3:39pm by RN S11: "discoloration to rt (right) foot, all digits black. Dorsal aspect of rt foot with transparent appearance, yellow in color. Red streak 2 cm in width radiating from knee down to top of rt foot. No pulses palpable or with doppler to dorsal pedal or posterior tibial. Temp. (temperature) cold to the touch from tip of toes to midway up tibia. Lt (left) lower extremity warm to the touch, skin tone normal in color. Weak palpable DP (dorsal pedal) pulses noted. See photos attached to medical record". Review of the photos revealed no documented evidence of the location of the wounds, the signature of the nurse who photographed and entered the photos into the medical record, and there was no documented evidence of a completed skin assessment flowsheet attached to the photos as required by hospital policy.

Review of the "Imaging Report" of the ultrasound of the right arterial lower extremity performed and read on 05/10/12 at 5:13pm revealed the impression of "occlusion of in situ right fem pop (femoral popliteal) graft with no flow in the infragenicular vessels".

Review of Patient #3's "History & Physical" dictated on 05/10/12 at 8:02pm by Physician S26 at Hospital A revealed the following: History of Present Illness ... "We spoke to the emergency room physician who said the foot was ice cold as well as no function in the right foot in which he suspected embolic event from his atrial fibrillation; therefore, he was immediately put on IV (intravenous) heparin and sent to us for definitive care. ... Physical Examination... Vascular: Nonpalpable right lower extremity pulses. Plus 2 left femoral with +1 popliteal and pedal pulses. Musculoskeletal: The entire right lower extremity is cold to touch. The patient has no function of the right lower extremity. The right foot is mottled with skin blistering and the entire all 4 compartments of the right lower extremity are dead as well as the right foot. There is skin sloughing of the right foot and anterior calf. ... Plan Non--salvageable right lower extremity: Since this patient has non-salvageable right lower extremity and he does have altered mental status, this may be because of the dead tissue in the right lower extremity. Therefore we will perform an emergent right above-knee amputation...".

In a face-to-face interview on 05/24/12 at 1:25pm, PT S9 indicated that she did Patient #3's PT evaluation on 05/07/12. She further indicated that he had TED hose on, and she didn't remove them. She further indicated that she couldn't remember if his SCDs were on. S9 indicated Patient #3 was very sensitive to her touch when she moved the toe part of the TED hose on the right foot. She further indicated he had a bunion pad on the right inner big toe and discoloration to the top of the foot. S9 indicated she could see through the TED hose that there was discoloration to the right heel. She further indicated that she reported that he was sensitive to touch and her observations of the appearance of his right foot and heel to RN S14.

In a face-to-face interview on 05/24/12 at 1:35pm, RN S10 indicated that he had been employed at this hospital since March 2012. He further indicated he was the RN who discharged Patient #3 on 05/10/12. S10 indicated he performed a "focused assessment" based on Patient #3 having had an appendectomy. He further indicated he looked at the bandaids applied to Patient #3's abdomen, checked his bilateral radial and pedal pulses, and did not remove his TED hose. S10 indicated Patient #3 did not have a palpable right pedal pulse that he noticed. He further indicated that it was a busy day, which was not an excuse, but he didn't do anything related to the absent pedal pulse and did not assess his lower extremities. S10 indicated he assumed most patients needed a doppler to check for pedal pulses, but he didn't have time to get a doppler. He further indicated that he did not notice any discoloration to Patient #3's right foot. S10 indicated that he did not report the absence of a right pedal pulse to the physician or the charge nurse.

In a face-to-face interview on 05/24/12 at 2:00pm, RN S11 indicated that she was the RN working in the emergency department when Patient #3 returned on 05/10/12 after having been discharged earlier the same day. She further indicated Patient #3's toes on the right foot were black eschar, and the top of the foot was yellowed.

In a face-to-face interview on 05/24/12 at 2:15pm, Unit Director RN S12 indicated when she was notified by the emergency department (ED) that Patient #3 had returned, she went to observe his extremities. She further indicated that she brought 3 of the nurses who had cared for Patient #3 during his hospital stay with her, one of whom was RN S10. She further indicated that two of the 3 nurses told her that Patient #3's leg did not look like it did in the ED when they had cared for him on the 1st South unit. She further indicated that RN S10 told her that his (#3) leg looked like it did when he discharged him earlier that day.

In a face-to-face interview on 05/24/12 at 2:40pm, RN S13 indicated she cared for Patient #3 on the night shifts of 05/05/12, 05/06/12, and 05/09/12. She further indicated that she removed his TED hose on 05/06/12, and his legs were "a little discolored", blancheable, and pulses present with a skin tear to the front of the right leg. S13 could offer no explanation for not documenting the skin tear to the front of the right leg. When asked what she meant by "a little discolored", S13 indicated it was mottled, dark but not gray, and a little transparent but could not describe the color. She further indicated that both legs looked the same. S13 indicated that did not remove the TED hose on 05/09/12 and did not assess the lower extremities. She further indicated she felt for pedal pulses, and both were present. S13 indicated Patient #3 had SCDs on all three shifts that she worked. She further indicated that she usually removed a patient's TED hose 1 of 2 nights when she worked 2 nights in a row. S13 confirmed that she was required to complete a head-to-toe assessment initially at the start of the shift and assess by diagnosis every 4 hours thereafter. When asked how she could perform a head-to-toe assessment without removing the TED hose, S13 answered "I can't".

In a face-to-face interview on 05/24/12 at 3:00pm, RN S14 indicated that she cared for Patient #3 on 05/07/12 and 05/08/12. She further indicated that although her documentation revealed that Patient #3 did not have SCDs and TED hose on, he did have them in place. She could offer no explanation for her documentation not matching what she observed. S14 indicated that on 05/07/12 she pulled the TED hose half-way down, got called from the room, and returned to pull the hose back up but never removed them. She further indicated she changed the dressing to the right great toe, and it looked like a skin tear, corn, or scrape. She further indicated that did not check for wound care orders and just assumed there were orders. S14 indicated she used Saf-klenz, Saf-gel, and applied a bandaid. S14 indicated PT S9 reported that Patient #3 had softness noted to his heel, and she (S9) applied heel bows. She further indicated it was at this time that she went to assess the patient and got called from the room. After review of the record, RN S14 indicated she remembered the heel bows being reported but didn't remember anything about his pain. She further indicated she remembered Patient #3 having discoloration to the leg, but she didn't remember if she observed it or if it was reported to her. S14 indicated when she pulled the TED hose half-way back, she saw redness along the shin of the right leg. S14 indicated that she was required to perform a head-to-toe assessment of each patient every shift. When asked how she could perform a head-to-toe assessment without removing the TED hose, S14 answered that she can't do a complete head-to-toe assessment without removing the TED hose.

In a face-to-face interview on 05/25/12 at 7:55am, Physician S8 indicated he was the emergency physician who saw Patient #3 on his initial visit with acute appendicitis and when he returned on 05/10/12 after having been discharged earlier the same day. He further indicated there was no specific skin abnormality at the time of his first visit on 05/02/12. S8 indicated at the time of the second visit on 05/10/12, Patient #3's right lower extremity was discolored and very little blood flow. He indicated that the ultrasound performed during this visit revealed that he had a previous graft that was occluded and no flow to the right lower leg. When asked if the SCD or TED hose could have contributed to the condition of the right leg, S8 indicated he couldn't answer the question, since he was not a vascular surgeon. When asked if an earlier assessment of the changes to Patient #3's right leg could have prevented the need for amputation, S8 indicated it was only his opinion that yes it could, but this answer was not based on an educated standpoint of being a vascular surgeon.

In a face-to-face interview on 05/25/12 at 8:30am, Physician S15 indicated that he was Patient #3's attending physician. He further indicated there was no gross abnormality to Patient #3's bilateral feet and legs when he was admitted on 05/02/12. When asked if the SCD or TED hose could have contributed to the circulatory problem of the right leg, S15 answered "not really. S15 indicated he checked for swelling of the feet during his visits, but he didn't open the SCDs or lower the TED hose to see his legs. He further indicated the staff did not report any changes to the lower extremities to him. When asked if an earlier assessment of the changes to Patient #3's right leg could have prevented the need for amputation, S15 indicated that if it was detected in time it could be prevented, but he didn't know how his surgery (appendectomy) had affected the thromboembolytics. He further indicated if it was detected in time, thromboembolytics could have been prescribed to dislodge the clot.

In a face-to-face interview on 05/25/12 at 9:40am, LPN S16 indicated that she was working in the ED when Patient #3 was first brought in with acute appendicitis. She further indicated his legs and feet were a little discolored with purplish bruising. S16 confirmed that she did not document this observation. She indicated that cared for Patient #3 on the unit on 05/07/12 on the night shift. S16 indicated he had bruising/discoloration to bilateral lower extremities. She further indicated she pulled the TED hose down bit didn't remove them. She further indicated Patient #3 had bilateral pedal pulses, and the extremities were warm. She further indicated he had a bandage to the right great toe which was something he came in with from the nursing home. S16 indicated on 05/08/12 on the night shift Patient #3 had SCDs and TED hose on. She further indicated that she lowered the the TED hose, and he had a bandaid to the right great toe with a new skin tear to the heel. S16 indicated he had pulses to both feet, and both lower extremities were warm. She further indicated there was what looked like bruising, the same that she had observed on his presence in the ED on 05/02/12. She further indicated that it was not anything that was reportable.

Patient #4
Review of Patient #4's medical record revealed he was a 74 year old male admitted with a diagnosis of COPD (chronic obstructive pulmonary disease) and Cough. He was discharged on 04/20/12.

Review of Patient #4's "Admit Assessment - General" performed at 1804 (6:04pm) on 04/18/12 by RN S24 revealed the following wounds:
"Incisions/wounds/bruises/abrasions/rashes/ulcer: 3rd lt (left) toe, round ulcer to center of lt sole of foot, and LLE (left lower extremity) achilles area";
Location #1: left foot 4 cm wide by 5 cm long by 0.5 cm depth, Stage III, tunneling and undermining with no documented evidence of presence or absence, periwound erythema, drainage yellow; Tissue Type: granulation yes, epithelialization yes, slough no, eschar no; Dressing Saturation: scant; Odor: mild; Comment: LLE pressure ulcer to achilles area;
Location #2: left foot 1 cm wide by 2 cm long with no documented evidence of the presence or absence of depth, tunneling, or undermining; no documented evidence of staging; periwound intact; no drainage,dressing saturation, or odor; Tissue Type: no granulation, epithelialization, slough, or eschar; Comments: see pictures on chart;
Location #3: left foot 2.5 cm wide by 4 cm long with no documented evidence of the presence or absence of depth, tunneling, or undermining; no documented evidence of staging, periwound tissue, and drainage; Tissue Type: no granulation, epithelialization, and slough, eschar yes; moderate dressing saturation and mild odor; Comments: see pictures on chart, 3rd left toe.
Further review revealed no documented evidence that the physician was notified of the wounds and orders received for wound care.

Review of Patient #4's wound photographs taken 04/18/12 revealed no documented evidence of the location of each wound, the time the photographs were taken, and the signature of the nurse who photographed the wounds and entered them into the medical record. Further review revealed no documented evidence of a completed skin assessment flowsheet attached to the photos as required by hospital policy.

Review of Patient #4's entire medical record revealed no documented evidence of physician orders for wound care and that wound care had been provided during his stay.

In a face-to-face interview on 05/24/12 at 4:10pm, Unit Director RN S12 confirmed that there was no documentation of wound care being provided to Patient #4 during his hospital stay.

In a face-to-face interview on 05/25/12 at 8:30am, Physician S15 indicated he usually ordered wound care for his patients. He further indicated that if the patient was admitted from a nursing home, he would usually continue the same wound care that was being done at the nursing home. After reviewing Patient #4's medical record, S15 indicated that the patient had been a patient here before, and the nurses were to continue the same wound care that was provided during that admission. When asked if he had written an order for wound care for this admission, S15 indicated that he did not see an order written for wound care.

Patient #5
Review of Patient #5's medical record revealed she was a 94 year old female admitted on 05/02/12 with diagnoses of Hyperosmole Non-Ketotic Coma and Urinary Tract Infection. Further review revealed she was discharged on 05/11/12. Review of Patient #5's "Discharge Summary" revealed her diagnoses included severe dehydration with associated hyperosmolar coma secondary to new onset diabetes mellitus type 2 and a significant elevation of blood sugar over 900, probable sepsis secondary to wound infection, severe dementia secondary to multiple cerebrovascular accidents, at least stage III or IV renal failure, new onset diabetes mellitus type 2, hypertension, peripheral artery disease, and hypothyroidism.

Review of Patient #5's "Admit Assessment - General" documented by