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REHABILITATION HOSPITAL OF OVERLAND PARK
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on policy review, record review, and interview the hospital failed to ensure nursing care was evaluated by a registered nurse on an ongoing basis to ensure that staff were providing the appropriate assessment and care for 6 (Patient 1, 2, 3, 4, 5 and 10) of 10 patient records reviewed. This deficient practice places the patient at risk for development of wounds, deterioration of current illness, infection, and harm.
Findings Include:
Review of the facilities policy titled, "Guidelines for Nursing Care" Revised March 28, 2022, showed "POLICY" To ensure quality patient care, certain standards of care must be upheld. The following table outlines basic nursing tasks and designates the minimum frequency with which these tasks must be performed to maintain quality care. A specific physician order will supersede the minimum frequencies noted below.
... Hygiene: Patient hair combed/shaved; Daily and PRN, If no contraindication, bath/ shower; Every other day and as per patient request Bed linen changed 3 times week and PRN, Draw sheets, incontinent pads, gown changed PRN Oral care Daily and PRN, Oral care for NPO, tube feedings, ventilated patients, Every shift, and PRN.
Activity and Mobility: Bedfast patient turned and documented; Every 2 hours and PRN Patient Rounding; Minimum every 2 Hours, Non-bedfast patients out of bed (OOB) to chair; Per physician's order; may ambulate patient according to physician order.
Review of facility policy titled, "Nursing Documentation" revised 3/2022, showed " ...The Nursing Services department will provide for a uniform method of documentation that is in compliance with Joint commission standards and federal/state regulation.
PROCEDURE: The Admission Nursing Physical Assessment and individual plan of care will be completed by an RN on admission. A patient focus assessment will be documented in the patient care record at least once per twenty-four (24) hour period by a Registered Nurse. ... RN assessment will be completed on each patient every 24 hours. This is documented via the daily nursing assessment form and corresponding daily patient care record.
Patient 1
Review of Patient 1's discharged medical record showed a 54-year-old female admitted on 02/10/23 with an admitting diagnosis of Malignant Neoplasm of the Brain (fast growing Brain Tumor), seizures (electrical activity in the brain), temporal lobe (part of brain that processes emotions), Gastroesophageal reflux (GERD), Hypothyroid (thyroid hormone too low), Left Mesial temporal nodule (abnormal growth).
Review of Patient 1's Treatment plan showed: Physical therapy consulted for gait training, assistive device evaluation/ training, transfer training. Occupational therapy consulted for ADL training; Speech therapy consulted on admission; cognitive deficits are present. Nursing to monitor routinely for basic needs.
Review of "OT Treatment Record dated 02/14/23 at 12:00 PM by Staff Q Occupational Therapy Registered (OTR) showed " ...Pt spouse explained patient need to return to bed due to (d/t) fatigue from being left seated in wheelchair (w/c) for hours. Pt brief checked - brief and chuck saturated with urine. Pt spouse asked when Pt had a shower."
Review of "OT Treatment Record and ADL Flowsheet" showed that Patient 1 received two bed baths on 02/15/23 and 02/16/23 during her 7-day inpatient stay.
Review of "CNA Daily Plan of Care" showed Patient 1 Outcomes/Goals: 1. Patient 1 will receive Optimal Care from the CNA Interventions/Education: 1. ADL Flowsheet Every 2 Hours.
Review of Patient 1's "ADL Flowsheet" for dates of 02/11/23 to 02/13/23 showed facility staff failed to document on the ADL Flowsheet every 2 hours for the following dates and times:
On 02/11/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on the ADL Flowsheet at 6:00 PM and 8:00 PM.
On 02/12/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on the ADL Flowsheet at 12:00 AM, 6:00 PM, 8:00 PM.
On 02/13/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on the ADL Flowsheet at 12:00 AM, 6:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, 6:00 PM.
During an interview on 03/08/23 at 3:47 PM with Staff Q Occupational Therapist Registered (OTR) stated that, OT helps nursing with the baths and essentially patients are offered a shower during the initial OT evaluation. Staff Q OTR stated that most of my patient have either a shower or bed bath goal. Staff Q OTR stated that, the patients usually will get a shower twice per week. Staff Q OTR stated that, the nursing staff rarely complete a shower. When asked about Patient 1 Staff Q stated that the patient needed a bed bath, technically the nurses should have given her a bed bath. There were times when Patient 1 had an incontinent episode and it looked like she had been that way for a while. Staff Q OTR stated that the patients are not being changed consistently every two hours as appropriate.
Patient 2
Review of discharged medical record shows a 52 year old male admitted on 01/15/23 with an admitting diagnosis of Cervical Myelopathy (compression of the spinal cord), cervical spinal cord compression secondary to severe cervical spinal stenosis(spinal canal is too small for the spinal cord and nerve roots), Acute blood loss Anemia, Diabetes (DM II), Hypertension (HTN), Diabetic peripheral neuropathy (numbness or weakness), gait disturbance, Chronic Kidney Disease (CKD III), status post C3-7 Post lateral arthrodesis (neck joint fusion).
Review of Patient 2's Treatment plan showed, consult rehabilitation services to help guide patient therapy and rehabilitation. Fall precautions. Consult Physical Therapy (PT) and Occupational Therapy (OT). Encourage ambulation for Deep vein thrombosis(clot) (DVT) prophylaxis.
Review of OT initial evaluation showed Patient 2 received a bath on 01/16/23. Review of the OT Treatment Record showed Patient 2 received a sponge bath on 01/21/23. Patient 2 received only two baths during his 8-day inpatient stay.
Review of "CNA Daily Plan of Care" showed Patient 2 Outcomes/Goals: 1. Patient 2 will receive Optimal Care from the CNA Interventions/Education: 1. ADL Flowsheet Every 2 Hours.
Review of documentation titled "Nursing shift assessment" dated 01/22/23 showed the daily nursing shift assessment was completed by a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) co signature was not documented in within 24 hours.
Review of Patient 2's "ADL Flowsheet" for dates of 01/17/23 to 01/23/23 showed the facility staff failed to document on the ADL Flowsheet every 2 hours for the following dates and times:
On 01/17/23 the CNA failed to document repositioning/turning, toileting needs, and hygiene care on ADL Flowsheet at 6:00 AM, 8:00 AM, 10:00 AM, 6:00 PM, and 8:00 PM.
On 01/18/23 the CNA failed to document repositioning/turning, toileting needs, and hygiene care on ADL Flowsheet at 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM.
On 01/19/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 7:00 PM.
On 01/20/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 7:00 PM.
On 01/21/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 5:00 AM, 8:00 PM, 10:00 PM.
On 01/22/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 5:00 AM, 6:00 PM.
On 01/23/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 1:00 AM.
Patient 3
Review of current medical record shows Patient 3 is an 80-year-old male who admitted on 03/03/23 with an admission diagnosis of Traumatic Subdural Hemorrhage with loss of consciousness status unknown.
Review of OT Initial evaluation dated 03/04/23 showed Patient performed shower seated.
Review of the OT objective notes dated 03/06/23 and 03/07/23 failed to show Patient 3 received a shower.
Review of "CNA Daily Plan of Care" showed Patient 3 Outcomes/Goals: 1. Patient 1 will receive Optimal Care from the CNA Interventions/Education: 1. ADL Flowsheet Every 2 Hours.
Review of Patient 3's "ADL Flowsheet" for dates of 03/04/23 to 03/07/23 showed the facility staff failed to complete charting on ADL Flowsheet every 2 hours for the following dates and times:
On 03/04/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 6:00 PM, 8:00 PM.
On 03/05/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 7:00 PM, 11:00 PM.
On 03/07/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 2:00 PM, 4:00 PM, 8:00 PM.
Patient 4
Review of current medical record showed an 87-year-old female admitted on 03/02/23 with an admitting diagnosis of Malaise (Fatigue) and generalized weakness.
Further review of Patient 4's medical record failed to show Patient 4 received a shower or bath since admission on 03/02/23.
Review of "CNA Daily Plan of Care" showed Patient 4 Outcomes/Goals: 1. Patient 1 will receive Optimal Care from the CNA Interventions/Education: 1. ADL Flowsheet Every 2 Hours.
Review of Patient 4's medical record documentation titled "ADL Flowsheet" for dates of 03/02/23 to 03/06/23 showed the facility staff failed to complete charting on ADL Flowsheet every 2 hours for Patient 4 for the following dates and times:
On 03/02/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 8:00 PM, 10:00 PM.
On 03/03/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 1:00 AM, 5:00 PM.
On 03/04/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 2:00 AM, 4:00, 6:00 AM, 8:00 PM, 10:00 PM.
On 03/05/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM, 8:00 PM, 10:00 PM.
On 03/06/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM.
Patient 5
Review of discharged medical record showed an 84-year-old female was admitted on 01/05/23 with an admitting diagnosis of Hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction affecting left dominant side and dismissed on 01/20/23 to home with home health care.
Review of ADL Flowsheet, nurse's notes and OT records showed Patient 5 was bathed only 3 out of the 15 days while inpatient between the dates of 01/06/23 to 01/20/23.
Review of "Nursing Shift assessment" dated 01/13/23 showed that an LPN completed the nursing shift assessment, and the RN Co-Signature was not completed within 24 hours.
During an interview on 03/08/23 at 10:22 AM, Staff A Director of Quality when asked about Patient 5 chart on 01/13/23 if there was RN co-signature. Staff A stated, "No it looks like we missed that one."
Review of "CNA Daily Plan of Care" showed Patient 5 Outcomes/Goals: 1. Patient 1 will receive Optimal Care from the CNA Interventions/Education: 1. ADL Flowsheet Every 2 Hours.
Review of Patient 5's "ADL Flowsheet" for dates of 01/06/23 to 01/20/23 showed the facility staff failed to complete charting on ADL Flowsheet every 2 hours for the following dates and times:
On 01/06/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 6:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 6:00 PM, 8:00 PM, 10:00 PM.
On 01/07/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 12:00 PM, 2:00 PM, 7:00 PM, 9:00 PM, 11:00 PM.
On 01/08/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 1:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 9:00 PM, 11:00 PM.
On 01/09/23 the CNA failed to document reposition/turning, toileting needs, and hygiene care on ADL Flowsheet at 1:00 AM, 3:00 AM, 5:00 AM, 7:00 AM, 11:00 AM, 1:00 PM, 6:00 PM, 11:00 PM.
On 01/10/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 1:00 AM, 3:00 PM, 5:00 PM.
On 01/11/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 8:00 PM, 10:00 PM.
On 01/13/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 1:00 AM, 3:00 AM, 1:00 PM, 3:00 PM, 8:00 PM.
On 01/14/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM.
On 01/15/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 12:00 AM, 2:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM, 10:00 PM.
On 01/16/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 12:00 AM, 2:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM, 10:00 PM.
On 01/17/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 3:00 AM, 7:00 AM, 11:00 AM, 1:00 PM, 3:00 PM, 5:00 PM, 7:00 PM, 11:00 PM.
On 01/18/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 3:00 AM, 11:00 AM, 1:00 PM, 7:00 PM, 11:00 PM.
On 01/19/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 1:00 AM, 5:00 AM, 11:00 AM, 1:00 PM, 3:00 PM, 5:00 PM.
On 01/20/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 8:00 AM.
Patient 10
Review of Patient 10's discharged medical record showed an 90 year old male admitted 12/18/22 with an admitting diagnosis Right lower extremity pain secondary to degenerative polyarthritis, Coronary Artery Disease (CAD), Essential hypertension, Hypokalemia (low potassium), anemia, Hyperlipidemia (too many lipids), history of cerebral vascular accident (CVA) with no residual deficit, Chronic Obstructive Pulmonary Disease (COPD), Benign Prostatic hyperplasia (BPH), Lymphedema (Buildup of fluid in soft tissue when the lymph system is damaged) of the lower extremities' Mobitz type 1 second-degree AV block (block in the heart due to irregular heart rhythm) Mobility, transfer and ADL deficits secondary to above.
Review of Patient 10's Treatment plan showed: Consult Physical and Occupational therapy. monitor Basic Metabolic Profile (BMP) and magnesium level. Provide patient with nutritional support and bowel program.
Review of wound care physician consultation note dated 12/23/22 showed "the Right gluteal area has a deep tissue injury that is non blanching bowl there is no induration or signs of infection. The sacral area has a small sacral split with good granulation, slight drainage and no signs of infection."
Review of Patient 10's medical record documentation titled "Nursing Shift Assessment" dated 12/19/22 and 01/01/23 showed that an LPN completed the nursing shift assessment and that an RN co signature was not completed within 24 hours.
Review of "CNA Daily Plan of Care" showed Patient 10 Outcomes/Goals: 1. Patient 1 will receive Optimal Care from the CNA Interventions/Education: 1. ADL Flowsheet Every 2 Hours.
Review of Patient 10's "ADL Flowsheet" for dates of 12/19/22 to 01/01/23 showed the facility staff failed to complete charting on ADL Flowsheet every 2 hours for the following dates and times:
On 12/19/22 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 5:00 AM.
On 12/20/22 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 11:00 AM, 1:00 PM, 3:00 PM, 5:00 PM.
On 12/21/22 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 5:00 PM, 7:00 PM, 11:00 PM.
On 12/23/22 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 11:00 PM.
On 12/24/22 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 7:00 PM.
On 12/28/22 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 11:00 AM, 1:00 PM, 3:00 PM, 7:00 PM.
On 12/29/22 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 7:00 PM.
On 12/30/22 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 7:00 AM, 11:00 AM, 1:00 PM, 3:00 PM, 5:00 PM, 7:00 PM, 9:00 PM, 11:00 PM.
On 12/31/22 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 1:00 AM, 3:00 AM, 5:00 AM.
On 01/01/23 the CNA failed to document repositioning/turning, toileting needs and hygiene care on ADL Flowsheet at 1:00 AM, 5:00 AM.
During an interview on 03/08/23 at 2:28 PM, Staff P, Licensed Practical Nurse (LPN) stated that, the bath schedule is a sheet on the wall, even number rooms baths are completed one day, and odd number rooms are the next day, but we will give a bath upon request from patients or families. Staff P LPN stated that, if the patient was given a bath, then the Certified Nurse Assistant (CNA) would document it in the Activities of Daily Living (ADL) flowsheet, or the Occupational Therapist (OT) will document if the patient received a bath.
During an interview on 03/08/23 at 3:01 PM with Staff J Certified Nursing Assistant (CNA) stated that, the even number rooms are assigned for baths one day, and odd number rooms are assigned the next day. Staff J CNA stated, "I personally did not give any today (03/08/23)." Staff J stated, "I do hourly rounding, I always want to make sure the patients are ok if you check on them all the time it takes less time and ask questions such as do you want a snack, need changed, go to bathroom, or need a bath? Staff J CNA stated that, we document every two hours and I document at 7:00 AM, 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM and 5:00 PM.