HospitalInspections.org

Based on facility document review, policy review and staff interviews, it was determined the facility failed to supervise and evaluate the nursing care for each patient in accordance with the hospital's policy to turn bedfast patients every 2 hours and document the patient's position in 10 of 10 patients (#1, 2, 3, 4, 5, 6, 7, 8, 9, and 10).

The findings included:

Review of the Policy and Procedure for Wound Care Initial Plan of Care and Standards of Care revealed bedfast patients must be turned every 2 hours and the patient's position documented. This Policy and Procedure's issue date was 06/10/2008 and the last revised date was 04/01/2018.

During an interview with the Director of Quality Management on 06/19/18, she stated the Certified Nursing Aides and the Registered Nurses all turn the patients. She stated the Registered Nurses document the turning of patients in the medical records because the Certified Nursing Aides are not allowed to chart. She provided copies of each time the Registered Nurses documented when patient #3 was turned during her hospitalization. Review of these documents failed to reveal that, on any day during her admission, patient #3 was turned every 2 hours and her position documented. When asked for documentation to show that patient's #1, 2, 4, 5, 6, 7, 8, 9, and 10 were turned every 2 hours, she did not provide this documentation.

Review of patient #1 through 10's records revealed each of these patients are bedfast and ventilator dependent except patient #8. Their diagnoses and discharge plans are listed below:

#1- Ventilator dependent respiratory failure - aspiration pneumonia, status post spinal surgery - osteomyelitis with hardware removed, on wound vacuum, thoracolumbar spine wound, severe protein calorie malnutrition, chronic diarrhea, oropharyngeal dysphagia, septic shock. She is a Do Not Resuscitate.

#2- Respiratory failure ventilator dependent, hyper-capnic hypoxic in nature, end-stage chronic pulmonary disease, cerebrovascular accident, hypertension, hyperlipidemia, severe deconditioning, severe protein-calorie malnutrition. The family requested hospice and all active and aggressive management have been discontinued.

#3- Acute hypoxic respiratory failure on pressure support ventilation, atelectasis, seizures, anoxic encephalopathy secondary to hypoxic brain injury, acute kidney injury with worsening renal function, and deconditioning and weakness. Palliative care has been suggested to the family.

#4- Ventilator dependent respiratory failure, status post tracheostomy, extended spectrum beta lactamase Escherichia coli, status post motor vehicle accident with multiple injuries including intracranial bleed, right leg fracture with vascular compromise, eventually underwent right below the knee amputation, dysphagia with percutaneous endoscopic gastrostomy tube, deconditioning and functional decline.

#5- Acute respiratory failure with hypoxia, ventilator dependent respiratory failure, status post percutaneous endoscopic gastrostomy and tracheostomy, obstructing colon cancer, status post diverting colostomy, normocytic anemia, alkaline phosphatase elevation, dysphagia with percutaneous endoscopic gastrostomy tube placement, dementia/encephalopathy, bilateral pleural effusion, atrial fibrillation, gastrointestinal bleed, status post cerebrovascular accident, essential hypertension, diabetes mellitus type 2, deconditioning and functional decline. Patient is appropriate for hospice, but daughter wants to prolong life.

#6- Acute respiratory failure on mechanical ventilator, Pneumomediastinum, dysphagia with vocal cord paralysis since 1999. abdominal pain with history if esophageal rupture, pleural effusion, diagnosis of lung mass, hypertension, gastrointestinal bleed, anemia, status post septic shock, status post thoracotomy, dysphagia with percutaneous endoscopic gastrostomy tube, deconditioning and functional decline.

#7- Large left middle cerebral artery cerebrovascular accident with right hemiparesis, congestive heart failure with ejection fraction of 35%, aphasia secondary to cerebrovascular accident, oropharyngeal dysphagia with percutaneous endoscopic gastrostomy tube placement, encephalopathy, lung mass, undiagnosed, aspiration pneumonia, status post antibiotic treatment, severe deconditioning, chronic bedbound state.

#8- Coronary artery disease, dyslipidemia, hypertension, right knee infection and wound dehiscence, hypothyroidism, chronic pain, narcotic dependence, osteoarthritis, status post evacuation of the left common iliac artery stent placement, peripheral artery disease, anxiety and depression, deconditioning and functional decline. Was discharged home on 04/04/18.

#9- Hypercapnia hypoxic respiratory failure, obstructive sleep apnea, chronic obstructive pulmonary disease, sepsis secondary to above knee amputation stump, status post debridement, cardiomyopathy with an ejection fraction of 20%, severe protein-calorie malnutrition, depression, end-stage renal disease, on hemodialysis, hypertension, severe protein-calorie malnutrition. Expired 03/28/18.

#10- Ventilator-Dependent respiratory failure, status post tracheostomy, Spina-bifida, bilateral pleural effusion, anoxic encephalopathy, stage IV sacral decubitus ulceration, cardiac arrest, status post resuscitation, status post ventriculoperitoneal shunting. The patient was discharged to hospice on 04/30/18.

During an interview with the Director of Quality Management and the Chief Executive Officer, at the time of exit, they stated the facility will soon be implementing a new computer program for medical record documentation. The facility is unsure if the program will include a section for documentation of repositioning of patients.