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Based on medical record review, policy review, and interview the facility failed to adhere to the restraint policy in the following areas: obtaining the signature of the physician contacted to initiate a restraint; a physician evaluation or telephone update for continued use of the restraint after the first twelve hours with a concurrent order; documentation of the decision to terminate the restraint; and the type of restraint used to limit one patient's (#3) mobility of thirty-one patients reviewed.

The findings included:

Patient #3 was admitted on September 19, 2012, with admitting diagnoses including bilateral Pneumonia, Loculated Empyema with Pneumothorax, and Lymphoma.

Medical record review revealed during this hospital stay the patient was mechanically ventilated post operatively on October 25 & 26, 2012, following Left Lung Decortation and a Mini Thoracotomy.

Review of the facility's policy titled Restraint Use revealed, "...restraint Use Procedure...E. Restraint Orders...attending physician must be notified and given an update...within twelve hours of restraint initiation. A written or verbal order for the continuation of the restraint use shall be obtained at this time...A written order is required by the physician within twenty-four hours of restraint initiation...L. Documentation 1) Documentation in the medical record of each restraint episode shall include: B) Pre-restraint assessment and Plan of Care...K) decision to terminate restraint use.

Review of the documentation tool, Restraint Order & Documentation Flowsheet, for patient #3 revealed the initial day a restraint was applied, October 25, 2012, at 2:44 p.m., did not include the type of restraint used in the order and was not signed by a physician. Review of the restraint flowsheet for October 26, 2012, revealed the order was written at 8:00 a.m., five hours after the twelve hour interval required by the facility's policy, the type of restraint was not designated, and the physician did not sign the order until "December 2012". Further review revealed the time the restraints were removed was not documented. Record review of the facility's Problem List, used for care planning, revealed the use of the restraint was not addressed.

Interview with the ADON (assistant director of nurses) at 2:00 p.m., on January 7, 2012, in the conference room, confirmed the facility's policy for the use of the restraint for patient #3 was not followed and the use of the restraint was not care planned.

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Based on record review, interview, and policy review the facility failed to keep nursing care plans current for five (#3,#4, #6, #21, and #30) patients of thirty-one patients reviewed.

The findings included:

Patient #3 was admitted on September 19, 2012, with admitting diagnoses including bilateral Pneumonia, Loculated Empyema with Pneumothorax, and Lymphoma.

Medical record review revealed during this hospital stay the patient was mechanically ventilated post operatively on October 25 & 26, 2012, following Left Lung Decortation and a Mini Thoracotomy.

Review of the facility's policy titled Restraint Use revealed, "...restraint Use Procedure...E. Restraint Orders...attending physician must be notified and given an update...within twelve hours of restraint initiation. A written or verbal order for the continuation of the restraint use shall be obtained at this time...A written order is required by the physician within twenty-four hours of restraint initiation...L. Documentation 1) Documentation in the medical record of each restraint episode shall include: B) Pre-restraint assessment and Plan of Care...K) decision to terminate restraint use.

Review of the documentation tool, Restraint Order & Documentation Flowsheet, for patient #3 revealed the initial day a restraint was applied, October 25, 2012, at 2:44 p.m., did not include the type of restraint used in the order and was not signed by a physician. Review of the restraint flowsheet for October 26, 2012, revealed the order was written at 8:00 a.m., five hours after the twelve hour interval required by the facility's policy, the type of restraint was not designated, and the physician did not sign the order until "December 2012". Further review revealed the time the restraints were removed was not documented. Record review of the facility's Problem List, used for care planning, revealed the use of the restraint was not addressed.

Interview with the ADON (assistant director of nurses) at 2:00 p.m., on January 7, 2012, in the conference room, confirmed the facility's policy for the use of the restraint for patient #3 was not followed and the use of the restraint was not care planned.

Medical Record review revealed patient #4 was admitted to the facility on January 1, 2013, with diagnoses of Direct Cellulitis of Right Foot, COPD, and Diabetes.

Review of admission progress notes, dated January 1, 2013, revealed Patient #4 had a "wound from plantar to dorsal side of right great toe...wound black with some bloody weeping (drainage) noted."

Review of Physician's orders dated January 7, 2013, revealed an order to "clean wound with soap and water, cover with dry gauze and wrap with kling."

Review of Patient #4's care plan, initiated December 31, 2012, revealed no interventions for the patient's wound until "Dressing on Right Foot" was added on January 7, 2013.

Medical record review revealed Patient #6 was admitted to the facility on December 21, 2012, with diagnoses of Left Planter Foot Ulceration.

Review of Progress Notes dated December 21, 2012, revealed, "Patient has pressure ulcer on the ball of left foot about the size of a silver dollar."

Review of Doctor's Orders revealed an order dated December 28, 2012, to "Pack decubitus to bottom of left foot."

Review of Nursing Orders dated December 29, 2012, revealed an order to, "pack open wound with Iodoform (medicated gauze), cover with sterile 4X4's (four inch square gauze dressings), left foot, secure with kling."

Review of Patient #6's care plan, dated December 21, 2012, revealed no interventions related to the patient's wound.

Interview with the Assistant Director of Nursing (ADON), on January 7, 2013, at 2:30 p.m., at the Third Floor Nurses Station, confirmed there were no interventions care planned for patients' #4 and #6's wounds. Further interview with the ADON confirmed nursing staff must address patients' wounds and/or dressings on the care plan.

Medical record review revealed patient #21 was admitted on September 24, 2012, with diagnoses including Diabetes, Dehydration, and Cellulitis of the Right Lower Leg.

Review of nursing skin assessments from September 24-28, 2012, revealed the right lower leg was assessed as impaired and on September 28, 2012, the nursing skin assessment stated, "Redness, swelling noted to RLE (right lower extremity) to right above knee, hot to touch, pt (patient) c/o pain to palpitation of area and pain when ambulating on extremity."

Review of the patient's problem list/care plan revealed the impairment and pain of the right lower leg was not included.

Interview on January 8, 2012, in the conference room at 10:00 a.m., with the Performance Improvement Coordinator, verified the patient's plan of care did not include the impairment and pain of the right lower leg or the impaired mobility due to the cellulitis.


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Medical record review revealed patient #30 was admitted to the facility on January 4, 2013, with diagnoses including Anemia and Hyperglycemia.

Medical record review of patient #30's Problem List/Care Plan revealed no interventions related to anemia or hyperglycemia.

Interview with the Unit Manager of the second floor, on January 8, 2013, at 10:30 a.m., in the second floor nurses station, revealed the patient was admitted to the facility with diagnoses including hyperglycemia and anemia on January 4, 2013. Further interview revealed ..."the nurses identify problems on the admission assessment and these problems are directly related the patients specific diagnosis..." Continued interview with the unit manager confirmed the "problem list" did not include any of the admitting diagnosis problems and the plan of care was not comprehensive.

Interview with Assistant Director of Nursing (ADON) on January 8, 2013, 10:45 a.m., in the second floor nurses station, confirmed the problem list and the patient's plan of care was not comprehensive to include the patients admitting diagnoses.

Review of the facility's "Problem Oriented Charting" policy, last review date August 2011, revealed, "The purpose of...charting by exception is to have an active individualized plan of care for each patient..."

Based on observation and interview, the facility failed to secure medications for one of two storage cabinets in the Emergency Department (ED).

The findings included:

Observation on January 7, 2013, at 10:00 a.m., in the fast track hallway of the Emergency Department, revealed an unsecured storage cabinet with patient care supplies and three vials of Zofran (medication for nausea) 4mg (milligrams) and one vial of Solu-Medrol (anti-inflammatory steroid for injection) 125mg. Futher observation revealed the cabinet was not in view from the nurses station and patients/vistors were observed in the hallway where the storage cabinet was located.

Interview on January 7, 2013, at 10:00 a.m., with the ED manager, in the fast track hallway of the ED, confirmed the medications were not secured in the unsecured storage cabinet and the medications should be secured in a locked cabinet.

Based on medical record review and interview the facility failed to address the nutritional needs of one patient (#3) of thirty-one patients reviewed.

The findings included:

Patient #3 was admitted on September 19, 2012, remained at the hospital for fifty-two days, and transferred to a long term acute hospital on November 10, 2012. Admitting diagnoses included bilateral MRSA Pneumonia, Loculated Empyema with Pneumothorax, and Lymphoma.

Medical record review revealed during this hospital stay a pulmonary embolus was diagnosed on October 3, 2012, a Subendocardial Myocardial Infarction on October 4, 2012, and the patient was mechanically ventilated post operatively on October 25 and 26, 2012.

Medical record review revealed the patient had the following procedures and surgeries: September 29, 2012 - Bronchoscopy (use of flexible scope to inspect the airway); October 3, 2012 - Thoracentesis (insertion of needle to drain the lung); October 7, 2012 - Chest tube placement; October 11, 2012 - Left Thorascope (inspection of the chest cavity with a scope) with Lung Decortation (surgical removal of lung tissue); October 25, 2012 - Left Lung Decortation and Mini Thoracotomy (removal of section of the lung); and November 6, 2012 - EGD (Esophagogastroduodenoscopy) (inspection of the stomach with a flexible scope) with placement of Corpak feeding tube.

Review of the registered dietician's initial assessment on September 21, 2012, revealed, "...Weight loss of 10 lbs (pounds) or more in 3 months. Diet order Cardiac..Supplement - Ensure or similar, TID (three times a day)...Average intake of meals last 24 hours 0-10%...To meet daily caloric needs patient needs 1300-1400 calories/day...Patient needs 55-68 grams of protein/day...Nutritional needs met: No due to poor intake and no appetite...Overall evaluation of nutritional status: ...poor due to poor intake and no appetite as evidenced by poor average intake. Low average intake may be due to Thrush and Chemotherapy. Patient reports soreness of the mouth due to Thrush. Patient also reports taste sensitivity and change may be due to Chemotherapy. Patient underwent RYGB (gastric bypass) surgery about 4-5 years ago..." Review of an informal note left to the doctor after the initial assessment revealed a multivitamin, iron, calcium, and B12 supplementation was recommended.

Review of the subsequent dietician assessments and/or recommendations in the medical record revealed the following:
September 27, 2012 - "...Average intake of meals last 24 hours: 0-25%, but always drinks 'at least half' of Ensure per family...intake less than adequate."
October 1, 2012 - "...Diet order: Cardiac, 6 small meals, Ensure TID...Less than adequate intake...taste changes."
October 8, 2012 - "...reoccurring poor intake. Patient reports an improved intake. However, nursing records reveal intake very low...Re-evaluate intake in 2-3 days..."
Record review revealed the patient was not re-evaluated until eight days later.
October 16, 2012 - "...Average intake of meals last 24 hours: less than 50%, some meals zero intake ..."
October 23, 2012 - "...Average intake of meals last 24 hours: 10% or less per nursing documentation ..."
October 29, 2012 - "Diet order: Full Liquid...poor intake... vomited three times yesterday per patient...Weight status:...loss from 199 pounds to 179 pounds...Low albumin (1.6) may also be in part due to poor nutritional intake...Overall evaluation of nutritional status: 10% body weight lost over 1 month and 6 days plus documented poor intake (less than 50% expected for patient) are evidence of malnutrition as per Aspen Academy Clinical Characteristics...Discussed poor nutrition status with MD (medical doctor). Recommend appetite stimulating medication trial..."

Review of the dietician's initial note left for the doctor on October 29, 2012, revealed the dietician raised the question of TPN or overnight enteral feedings to address the patient's malnourished status.

Medical record review of the physician orders from admission until dismissal to the Long Term Acute Hospital on November 10, 2012, revealed an order for Vitamin B12 and Vitamin D supplementation from day of admission. Review revealed the patient did not have a multivitamin, iron, or calcium supplementation ordered during stay. Review revealed an order for 'Magic Mouthwash 5 ml. by mouth every four hours as needed (to address mouth soreness and Thrush) on September 21, 2012. Review of orders revealed an appetite stimulate, Megace, was ordered on October 24, 2012, and was discontinued the next day on October 25, 23012.

Review of the orders revealed the patient was receiving several broad spectrum antibiotics capable of producing the possible side effects of altered taste, nausea, and/or vomiting including: Sulfamethoxazole/TMP 800/160 tablet twice a day from September 25 - October 25, 2012; Zosyn 4.5 grams intravenous every six hours from admission until dismissal; Fortaz 1 gram intravenous every eight hours from admission until September 25, 2012; Tobramycin with the dose and timing (every 8-12 hours) determined each day by the pharmacist from admission through September 25, 2012; and Vancomycin from September 25, 2012, through November 10, 2012, with the dose and timing determined each day by the pharmacist.

Review of the orders revealed the patient had one medication ordered to address nausea or vomiting, Phenergan 25 mg by mouth every six hours as needed on September 19, 2012, discontinued on October 11, 2012. Review of the orders revealed there was not a scheduled medication to address nausea.

Review of the Medication Record revealed the Magic Mouthwash was administered one time on September 21, 2012, by the nursing staff. Review continued and revealed the medication ordered for nausea and/or vomiting was given one time each day from day of admission through September 24, 2012.

Review of the medical record revealed the patient had a tube feeding began after placement of the feeding tube on November 6, 2012, of 'Jevity Ready To Hang' at 40cc/hour from 8:00 p.m., until 8:00 a.m. each day. Review revealed the patient had an initial calorie count completed from November 7-8, 2012, and was transferred on November 10, 2012.

Interview at 11:15 a.m., on January 8, 2013, in the conference room, with the Performance Improvement Coordinator verified there was no documentation of an interdisciplinary team effort to address the patient's malnourishment, verified there was not a comprehensive plan developed to address the problem of the patient's prolonged nausea and poor intake, and confirmed from four days after admission until the last four days of the patient's stay there was no significant approach developed to address the patient's malnourished state.

Interview at 2:15 p.m., with the registered dietician on January 8, 2013, in the conference room, confirmed efforts to address the patient's nutritional needs were not successful and interventions were not developed with the physician prior to November of 2012, forty-two days into the patient's stay.
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