HospitalInspections.org

Based on interview, record review and the facility's policy, it was determined the facility failed to have three (3) of ten (10) sampled Patients or the Patient's representative sign the Authorizations and Consent for Treatment Form during admission or during the hospitalization.

The findings include:

Review of the facility's policy titled, "General Authorizations and Consent", revised 06/18/06, revealed the purpose was to grant general consent for treatment. The policy stated, a general consent for treatment must be signed for every patient. If the patient is unable to sign and an appropriate representative is available, note on the consent form "The patient is unable to sign due to his/her medical condition" and have the form witnessed by two (2) employees.

Review of the Authorization and Consents form revealed information for consent to treat, consent to be photographed, telehealth, assignment of benefits financial responsibility, preadmission certification and release of information, certification/authorization for Medicare or Medicaid benefits, authorization for the release of information, independent status of Physicians, testing for infectious disease, personal equipment and valuables, semi-private and private accommodations differential, workers compensation authorization, notice of facility transfer, prescription and use of controlled substances. There was also a box to check if patient or the patient's representative received a copy of the Rights, Responsibilities and Conditions of Patients and a copy of the information from Medicare/Insurer.

Review of Patient #5's medical record revealed, Patient #5 was admitted through the Emergency department (ED), on 12/13/12, with diagnoses which included Acute Respiratory Failure, Pneumonia and Sepsis.

Review of Patient #8's medical record revealed, the patient was admitted through the ED on 12/03/12 with diagnosis which included Chest Pain and Pneumonia.

Review of Patient #9's medical record revealed, the patient was admitted through the ED on 12/21/12 with a diagnosis of Sepsis.

Review of the Authorizations and Consent for Treatment Forms for Patients #5, #8 and #9 revealed no documented evidence the patients or the Patients' representatives had signed the consent forms. Further review revealed the forms were witnessed by two (2) employees.

Interview with the Emergency Department Unit Manager, on 12/20/12 at 3:30 PM, revealed if a patient comes to the hospital through the emergency department and is unable to sign the general consent for treatment due to their condition upon arrival, it was the nurses' responsibility to have two (2) nurses sign the consent and document the reason the patient was unable to sign. She stated the Consent Form should then be copied and sent to the floor with the patient.

Interview, on 12/20/12 at 1:10 PM, with the House Administrator revealed every patient should have a signed consent to treat and in an emergency the Physician and the nurse should sign it on behalf of the patient.

Based on interview, clinical record review and review of facility's policy, it was determined the facility failed to ensure nursing personnel followed patient care orders and protocol for treatment of pressure ulcers for two (2) of ten (10) patients (Patient #1 and #10).

The findings include:

Review of facility's policy, "Alteration in Skin/Tissue Integrity Protocol (Actual) (Pressure Ulcer)" policy code PCS-V-02H, revised 04/2011, revealed patients with an Unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough) pressure ulcer would have an assessment of the pressure ulcer weekly to include measurement in centimeters (length/width/depth); Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) pressure ulcers did not have this measurement requirement. The facility policy further revealed for an unstageable pressure ulcer, nursing personnel were to implement actions listed in facility policy, "Alteration in Skin/Tissue Integrity Protocol (Potential)" policy code PCS-V-01G, revised 04/2011. This policy revealed patients should be repositioned every thirty (30) minutes to two (2) hours.

1. Review of the clinical record of Patient #1 revealed he/she was admitted to the facility on 11/28/12 with a Primary Diagnosis of Small Bowel Obstruction. On 12/06/12, the Physician ordered a consult with the Wound Ostomy Care Nurse (WOCN) for assessment of skin issues. The record further revealed, on 12/07/12, the WOCN assessed Patient #1 as having an unstageable coccyx pressure ulcer. Daily treatment ordered for this ulcer included applying medihoney gel after cleansing with normal saline and then secure with mepilex. Further review of the record revealed nursing personnel documented this coccyx pressure ulcer to be a Stage II instead of Unstageable from 12/07/12 until 12/19/12. Further review of Patient #1's clinical record, in the Patient Care Flowsheet, dated 12/18/12, revealed no documentation that the daily treatment regimen for the Unstageable coccyx pressure ulcer was done. Additional review of the record, in the Bedside Care Flowsheets, revealed there were three (3) periods in which there was no documentation that that patient was repositioned at least every two (2) hours. These periods were 12/09/12 at 11:00 PM to 12/10/12 at 2:00 AM; 12/10/12 at 4:00 AM to 8:00 AM; and 12/14/12 at 5:00 AM to 8:00 AM. Further review of Patient #1's record revealed there was no measurement of the Unstageable coccyx pressure ulcer from 12/07/12, when it measured one (1) centimeter (cm) by one (1) cm, until 12/19/12, when it measured two (2) cm by 2 cm. There were no weekly measurements of this pressure ulcer.

Interview with the WOCN, on 12/28/12 at 10:35 AM, revealed she knew the nurses were documenting Patient #1's coccyx ulcer as a Stage II instead of Unstageable and understood that it would have been reasonable to do so. She also revealed she did not specifically communicate this change in classification to nursing personnel but noted it was documented in the Progress Notes in the clinical record as Unstageable. She further revealed she believed the treatment plan for the coccyx pressure ulcer would have been the same, regardless of the classification.

Interview with the Unit Manager, on 12/28/12 at 4:55 PM, revealed Patient #1's treatment to the coccyx pressure ulcer should have been done on 12/18/12. She further revealed Patient #1 should have been repositioned at least every two (2) hours. She could offer no explanation as to why these actions were not done.

2. Review of the medical record of Patient #10 revealed he/she was admitted to the facility on 11/09/12 with Diagnoses which included Spinal Abscess and Stage III coccyx pressure ulcer. A WOCN consult was triggered from the Admission Nursing Assessment on 11/09/12 due to the Stage III pressure ulcer; however, the WOCN did not see Patient #10 until 11/14/12. The clinical record further revealed an additional daily treatment recommended by the WOCN was Santyl gel to the coccyx pressure ulcer and cover with mepilex. The Physician ordered this treatment, and it was implemented by nursing personnel on 11/15/12.

Interview with the WOCN, on 12/28/12 at 4:45 PM, revealed there was no facility policy that mandated a timeframe between the time of the consult and time the patient was evaluated. She did state, although unwritten, it was facility protocol that any consult she received must be initiated within seventy-two (72) hours. She further revealed that five (5) days exceeded the facility protocol, and Patient #10 should have been seen and evaluated within the seventy-two (72) hour timeframe. She could offer no explanation as to why this occurred with Patient #10.

Interview with the Vice-President for Patient Care Services, on 12/28/12 at 4:45 PM, revealed nursing had automatic skin care protocols so that appropriate interventions for alterations in skin integrity could be done before the WOCN had an opportunity to see the patient. She further stated a five (5) day span between consult request and evaluation was too long.

Based on interview, clinical record review and review of facility's policy, it was determined the facility failed to ensure the nursing care plan was updated to reflect a coccyx pressure ulcer for one (1) of ten (10) patients (Patient #1).

The findings include:

Review of facility's policy, "Patient Plan of Care" policy code PCS-II-62C, revised 06/2012, revealed each patient's plan of care was based on patient care needs identified through analyzing data obtained from nursing assessments and revised as indicated by subsequent assessments/observations.

Review of the clinical record of Patient #1 revealed he/she was admitted to the facility on 11/28/12 with a Primary Diagnosis of Small Bowel Obstruction. Patient #1 had an Unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough) coccyx pressure ulcer classified by the Wound Ostomy Care Nurse (WOCN) with treatment ordered on 12/07/12. The nursing care plan did not reflect this update or change in care from 12/07/12 until Patient #1's discharge on 12/21/12.

Interview with the Unit Manager of the Medical Surgical Floor, on 12/28/12 at 4:55 AM, revealed the nursing care plan for Patient #1 did not address the pressure ulcer on the coccyx. She further revealed Patient #1's nursing care plan should have been updated to reflect his/her change in condition/treatment.