HospitalInspections.org

Based on hospital policy review, medical record review, and staff interview, it was determined that 1 of 6 admitted patients (Patient #7) in the sample, the hospital failed to include the patient and/or patient representative in the development of the plan of care. Findings include:

Hospital policy titled "Case Management and Discharge Planning Description" states, "...Education in preparation for patient's discharge includes...helping the patient, family and/or lay caregiver understand the patient's treatment...teaching the patient, family, and/or lay caregiver what they need to know about care after discharge...active involvement of the patient, family...is encouraged throughout the discharge planning process..."

Hospital policy titled "Case Management Ongoing Discharge Planning Assessment (ODPA)" states, "...Roles and Responsibilities of Case Manager and Social Worker A. Engages the patient/family...to perform...an ODPA throughout the patient's hospital stay...discusses discharge options with patient/family..."

Patient #7 medical record review of the 8/24/21 admission revealed:
- no evidence that the patient, family, or caregiver were involved in the ongoing discharge planning process

This finding was confirmed on 10/17/22 at 3:25 PM with Employee 19, Senior Vice-President Clinical Essential Services, who stated the expectation is that the patient and family are to be involved with the discharge planning process.

Based on medical record review, document review, and staff interview it was determined that 2 out of 10 patients sampled (Patient #s 2 and 9) that the facility failed to obtain general consent for treatment. Findings include:

Facility policy titled "Privacy - Conditions for Treatment Form" states: " ...ChristianaCare is committed to obtaining patients' authorization for treatment and to inform them of service terms ... Staff member responsibilities: ... Register the patient and review the Conditions for Treatment and Financial Responsibility Acknowledgement Form ...Obtain the signature of the patient and/or patient's representative after explaining the form...If applicable, document the inability or refusal of the patient or their representative to sign the form. Registrars must check the applicable check box and initial the form ....If the patient is admitted to the hospital, the registration staff should attempt to obtain a signature on the form when circumstances allow ..."

A. Patient #9 medical record review revealed:
- no evidence patient signed the "Conditions for Treatment and Financial Responsibility Acknowledgement" form
- no evidence the patient provided consent to treatment

The finding of no evidence patient consented to treatment was confirmed on 10/18/22 at 2:00 PM with Employee 2, Manager Accreditation.


B. Patient #2 medical record review revealed:
- no evidence patient signed the "Conditions for Treatment and Financial Responsibility Acknowledgement" form
- no evidence the patient provided consent to treatment

This finding was confirmed with Employee 10, RN at 1:49 PM on 10/13/22.

Based on observation, document review, and staff interviews it was determined that the facility failed to supervise and evaluate the nursing care for 3 out of 10 patients (Patient #s 3, 5, and 6) sampled. Findings include:

I. Missing Vital Signs

A. Facility policy titled Vital Sign Assessment - Emergency Department dated 10/13/2021 states: "...Vital signs will be reassessed according to the patients Emergency Severity Index (ESI) level ...ESI 2 and ESI 3: vital sign reassessment Q2 (every 2) hours at minimum..."

Facility policy titled Standards of Care and Professional Nursing Practice states: "...Vital signs, consisting of temperature, pulse, respirations, and blood pressure will be taken at a minimum frequency of three times daily unless otherwise deemed necessary based on patient condition or ordered by the provider ..."

B. Per medical record review Patient #5 had vital signs taken upon arrival to the Emergency Department at 1735. No other vitals signs were taken for the remaining 7 hours of his stay.
This finding was confirmed by Employee 2, Manager Accreditation on 10/18/2022 at 2:56 PM.

C. Patient #3 medical record review revealed:
- patient triaged at Christiana Hospital ED on 8/23/22 at 7:45 PM with an ESI of 3 assigned
- vital signs completed 8/23/22 at 7:50 PM, 8/24/22 at 5:47 AM, 8/24/22 at 8:35 AM, 8/24/22 at 9:46 AM; no evidence of vitals completed between 8/23/22 7:50 PM to 8/24/22 5:47 AM (4 missed vital signs)

The finding of no evidence of vital signs being documented between 8/23/22 7:50 PM to 8/24/22 5:47 AM (4 missed vital signs) was confirmed on 10/13/22 at 11:11 AM with Employee 4, Director Clinical Operations - Emergency.

II. Missing turns

A. Facility policy titled Provision of Patient Care Plan states: " ...The process of caring for a patient includes: planning care, providing care, monitoring and determining the outcomes/response of care, modifying care, and coordinating follow-up ...Each provider's role and responsibility is determined by scope of practice, credentials, relevant licensure, certification, regulation, privileges, and demonstrated competence ..."

Facility policy titled Skin Integrity Care Management Guideline states that "Key Patient & Family Education Topics" includes "Rationale for pressure redistribution therapy/ importance of repositioning every 2 hours/ activity." The policy identifies "Change position every 1 hour (chair), every 2 hours (bed) and document" under treatment for pressure injury.

B. Medical record review for patient #6 (admitted on 12/6/2021) revealed:
--Order placed on 12/7/21 for turns to be done every 2 hours. This order was discontinued 4/7/22.
-Skin integrity assessment done on 12/7/21 at 3:42 PM shows the patient had a deep tissue pressure injury that was present on arrival.

-Turns were not done as follows:
-On 12/10/21 between 12:00 and 16:06 (4 hours and 6 minutes)
-On 12/14/21 between 10:01 and 14:25 (6 hours and 24 minutes)
-On 12/14/21 between 14:25 and 23:33 (9 hours and 8 minutes)
-On 3/17/22 between 6:30 and 12:38 (6 hours and 8 minutes)
-On 3/17/22 between 12:38 and 20:15 (7 hours and 37 minutes)

These findings were confirmed with Employee 11, RN on 10/19/22 between 9:48 and 11:14 am.

III. Missing nursing assessments/skin checks

A. Facility policy titled Standards of Care and Professional Nursing Practice states: " ...The nurse performs the nursing assessment on an 8-hour basis or more often as ordered and/or needed ..."

Facility policy titled Skin Integrity Care Management Guideline states: " ...Perform a Complete Skin Assessment ...Q8 [every 8] hours ...Evaluate patient's entire skin from head-to-toe ..."

B. Medical record review for Patient #6 (admitted 12/6/21) revealed:
-No assessment done of sacral pressure injury done 12/11/21 - 12/14/22 (4 days).

This finding was confirmed with Employee #11, RN on 10/19/22 at 10:44 AM.

Based on medical record review, facility policy review, and staff interviews, it was determined that for 2 of 6 admitted patients (Patient #s 7 and 9) in the sample, the hospital failed ensure that the nursing staff developed and kept current a nursing care plan for that reflected the patient's goals and the nursing care to be provided to meet the patient's needs. Findings include:

Facility policy titled Standards of Care and Professional Nursing Practice states: "...The Registered Nurse (RN) initiates the patient's plan of care within 8 hours of admission...The RN reviews and updates the patient's plan of care every 24 hours or more often a needed ..."

A. Patient #7 medical record review revealed:
- no evidence of a developed nursing care for the patient's admission from 9/24/21 to 10/1/21

This finding was confirmed on 10/17/22 at 2:50 PM with Employee 2, Manager Accreditation.

B. Patient #9 medical record review revealed:
- no evidence of a developed nursing care for the patient's admission from 3/9/22 to 3/16/22

This finding was confirmed on 10/18/22 at 1:05 PM with Employee 6, Patient Safety and Accreditation Coordinator.

Based on observation, policy review and staff interview, it was determined that the facility failed to ensure safe handling of 3 out of 3 observed potentially infectious medical waste containers. Findings include:

The facility policy titled: Stericycle Sharps Management Service/ Bio Systems Reusable Containers Program Procedure states "...once the Bio Systems Reusable Container is ¾ full, it is time for removal from the treatment floor and placement in the transport box."

The following was observed on a tour of the Emergency Department at the Wilmington Hospital location on 10/18/2022:

- Sharps containers greater than 3/4 full at rooms #25, #26, and #28.
- Potentially infectious waste exceeded the black full line on the containers.

This finding was confirmed on 10/18/2022 at 10:05 AM by Employee 17, RN.

Based on medical record review, policy review and staff interview, it was determined that the hospital failed to reevaluate the discharge plan for 1 of 6 (Patient #7) admitted patients in the sample. Findings include:

Hospital policy titled "Care Management Module - Documentation process for Care Management" states, "...Case Managers and Social Workers...documentation for ongoing assessments and follow-up care is completed at least every three days..."

A. Patient #7 medical record review of 8/24/21 admission revealed:
- "Ongoing Discharge Planning Assessments" documented on 9/16/21, 9/17/21, 9/22/21, 9/23/21 at 9:02 AM, and 9/23/21 at 11:04 AM; ongoing discharge planning assessments not completed within 3 days between 9/17/21 to 9/22/21

- Employee 19, Senior Vice-President Clinical Essential Services, stated during an interview on 10/17/22 at 3:25 PM that the expectation is for ongoing discharge planning assessments to be documented at least every 3 days.

The finding that ongoing discharge planning assessments were not completed within 3 days between 9/17/21 to 9/22/21 was confirmed on 10/17/22 at 3:25 PM with Employee 19, Senior Vice-President Clinical Essential Services.

Based on medical record review, policy and document review and staff interview, it was determined that for 1 of 6 discharged inpatients (Patient #2) in the sample, the hospital failed to discharge the patient with all necessary information for post-discharge care. Findings include:

Facility policy titled Case Management and Discharge Planning Description states: " ...Information related to the patients admission, including the patients' medical and psychosocial status, patient and family education that has been completed is communicated both verbally and in written format to the patient and/or their designated healthcare representative ...to provide for continuity of care ..."

Review of the medical record for Patient #2 (admitted 6/4/2022) revealed:

-Discharge instructions (signed by the patient's wife) dated 6/6/22
-My summary section states: "I was in the hospital for: You can quit smoking / using tobacco ..."
-My Next Steps section states: "Follow up with: ...Internal Medicine Service ..."

-Discharge summary note dated 6/6/22 states:
- Discharge diagnosis is listed as GI bleed, COVID-positive status

-Progress note dated 6/6/22 states:
-"Given active COVID infection with stable hemoglobin no recurrence of GI bleeding, recommend proceeding with an outpatient colonoscopy ..."

Discharge communication with patient and family did not reflect the patient's diagnosis on discharge or the plan to follow up for an outpatient colonoscopy.
This finding was confirmed with Employee 10, RN on 10/13/22 at 2:28 PM.