HospitalInspections.org

Based on document review and interview it was determined the Hospital failed to ensure there is enough staff available to care for the patients. This potentially affected the average daily census of 60 patients.

Findings included:

1. The Master Position Control worksheet was reviewed on 3/14/17. The control sheet included that the hospital has a budget of 45.9 FTEs (full time equivalents) for nurses. Currently there are 39.4 FTEs on staff. There are 4 nurse positions posted. The budget for CNAs (certified nursing assistant) is 30 FTEs, with 22.2 FTEs on staff. There are 9 CNA positions posted.

2. The first week of each month for December 2016, January 2017 and February 2017 actual hours per patient day were reviewed. The following days indicated the hospital was short staffed:
December 1st and 4th - night shift, short 1 CNA
December 2nd and 6th - day shift, short 1 CNA
December 7th - day shift, short 1 nurse
January 2nd and 6th - day shift, short 1 CNA
January 2nd, 3rd, 4th,5th, 6th and 7th - night shift -short 1 CNA
February 1st, 3rd, 5th, 6th and 7th - day shift, short 1 CNA
February 3rd, 4th and 5th - night shift, short 1 CNA
February 2nd - day and night shift, short 2 CNAs
February 6th and 7th - night shift, short 2 CNAs

3. During an interview on 3/14/17 at 11:30 AM, the Chief Clinical Officer (E#1) stated, "Currently there are 9 CNA and 3 RN openings. We have weekly position control meetings with the corporate recruiter to discuss our needs". E#1 stated that the corporate office schedules all interviews for applicants. E#1 stated that the hospital does run short on occasion.

A. Based on document review and interview, it was determined for 1 of 3 (Pt. #1) patients reviewed for repositioning, the Hospital failed to ensure patients were repositioned every two hours as ordered.

Findings included:

1. The Hospital policy titled, "Prevention and Treatment of Pressure Ulcers and non-pressure Related Wounds (release date 6/2016)" was reviewed on 3/13/17. The policy included, "Patient's not at high risk are evaluated for appropriate repositioning intervention needs and define that expectation in the patient's plan of care".

2. The clinical record of Pt. #1 was reviewed on 3/13/17 at 1:00 PM. Pt. #1 was a 62 year old female admitted on 12/1/16 with the diagnosis of acute respiratory failure requiring ventilator (breathing machine) management. A physician's order dated 12/1/16 at 8:24 PM included, "Reposition, apply turning wedge; apply pillows between legs to prevent direct pressure every 2 hours".

The turning schedule for 6 random days in Pt. #1's clinical record included the following days of more than 2 hours between repositioning:
12/14/17 from 12:00 AM to 4:24 AM (4 hours and 24 minutes), 12/23/16 from 3:56 AM - 8:00 AM (4 hours and 4 minutes), 1/19/17 from 9:41 AM - 12:43 (3 hours and 2 minutes) and 1/23/17 from 11:31 AM - 2:54 PM (3 hours and 23 minutes).

3. During an interview on 3/14/17 at approximately 10:00 AM, the Director of Quality Management (E#2) stated, "The patient should have been turned every two hours because of the physician order and on those days, it is not documented".

B. Based on document review and interview, it was determined for 1 of 2 (Pt. #1) patients reviewed for skin integrity, the Hospital failed to ensure skin breakdown was identified and treated timely.

Findings included:

1. The Hospital policy titled, "Physical Restraints (Violent and Non-Violent Behavior) and Seclusion (release date 6/2016)" was reviewed on 3/14/17. The policy required, "Ongoing Safety checks & monitoring (at least every two hours) by the patient's clinical team of the patient's response to the restraint, including any condition changes. ... All documentation of patient status should be in real time". The monitoring flow sheet required a skin integrity check every 2 hours.

2. The clinical record of Pt. #1 was reviewed on 3/13/17 at 1:00 PM. Pt. #1 was a 62 year old female admitted on 12/1/16 with the diagnosis of acute respiratory failure requiring ventilator (breathing machine) management. The clinical record included physician orders for bilateral wrist restraints dated 12/1/16 and every seven days thereafter until date of discharge (2/26/17).

The wound nurse (E#5) documentation dated 1/6/17 at 2:11 PM included, "altered skin conditions - skin tear: right wrist. Description - flat - 100% of epidermal flap lost".

A physicians' (MD#1) order dated 1/6/17 at 2:17 PM included, "Wound care: right wrist, cleanse wound with wound cleanser (pat dry), and apply dressing - non adhesive foam".

The wound nurse documentation (E#1) dated 1/19/17 at 4:30 PM included, "altered skin conditions - skin tear: left wrist. Description - linear (appears as if incision has been made). Skin tear: right wrist - healed".

The wound nurse documentation (E#1) dated 2/2/17 at 6:00 PM included, "skin tear: left wrist healed".

The daily Restraint Monitoring form included documentation every two hours of: Range of motion, fluids offered, toileting, comfort, hygiene maintained, safety management, mental status changes, skin integrity and circulatory status. The monitoring forms were dated from 12/1/16 (date of admission) to 2/26/17 (date of discharge). The clinical record lacked documentation of a change in skin integrity on the restraint flow sheet.

3. During an interview on 3/14/17 at 11:30 AM, the Chief Clinical Officer (E#1) stated, "The wound was caused by the restraint and because of how it looked, should have been identified by the nursing staff prior to me finding it. The restraint monitoring form should have included a change in skin integrity".