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272 HOSPITAL ROAD

CHILLICOTHE, OH 45601

NURSING SERVICES

Tag No.: A0385

Based on observation, medical record review, staff interview and policy review the facility failed to meet the condition of nursing based on the following findings.

The facility failed to provide accurate weights for two of 31 patients whose records were reviewed: (Patient #'s 18 and 26.) The facility failed to assess lack of skin integrity for two of two records of patients with wounds. (Patient #'s 27 and 25) The facility failed to maintain an accurate intake record for one of 31 patients whose records were reviewed. (Patient #18) See A0395

The facility failed to develop a care plan for two of two patients with wounds. (Patient #s 27 and 25). See A0396

The facility failed to comply with the policy for administration of medication. (Patient #31). See A0405.

RN SUPERVISION OF NURSING CARE

Tag No.: A0395

Based on medical record review, staff interview, and policy review, the facility failed; to provide accurate weights for two (Patients # 18 and #26) of 31 patients whose records were reviewed; to assess a lack of skin integrity for two (Patient #'s 27 and 25) of two patients with wounds from the sample of 31 records; to maintain an accurate intake record for one (Patient #18) of 31 patients reviewed. The facility census was 105.

Finding include:


The medical record of Patient # 27 was reviewed on 06/07/12, and revealed this patient had been an inpatient from 05/26- 05/31/12. The patient had been admitted from a nursing home with a diagnosis of deep vein thrombosis and a history of a recent hip surgery. The nursing assessment dated 05/26/12 identified a stage two pressure sore on the tailbone area, the presence of a black area and a blister on the left heel. The assessment lacked documentation of measurements of the wound and of the black and blistered area on the left heel. A comment, documented on a wound record dated 05/26/12, revealed the patient came with a stage two wound area on the tailbone that had no dressing", dressing put on until wound nurse can assess and write orders". There was no documentation of a wound assessment by the wound nurse until three days later on 05/29/12.

The wound care nurse's (Staff B) assessment and documentation on a physician's progress note, dated 05/29/12, revealed documentation of one measurement of the left heel, as 2 centimeters by 3.5 centimeters in size. There was no documentation of a measurement or mention of the tailbone wound. The medical record lacked documentation of measurements of the patient's tailbone wound for the five days the patient was an inpatient. There was no measurable way for the nurse to determine, at the time the patient was discharged, if the patient's wounds had deteriorated or improved.

Staff E confirmed this finding during an interview on 06/07/12 at 4:00 PM.

Review of the facility's policy 26.7 (5) III "Pressure Ulcer Care" revealed "the nurse will perform a complete skin assessment upon admission to the hospital setting. Patient's arriving with preexisting wounds or dressings will have the dressings removed and the wounds assessed/measured upon admission."

Review of Patient #18's medical record was completed on 06/07/12. The patient was admitted to the facility on 06/02/12 with a diagnosis of sepsis and dehydration. The physician order for the patient was to administer intravenous fluids at 150 cc's an hour continuously the day of admission. On 06/04/12, the hospital administered two units (200 ccs) of packed red blood cells (prbc) that was administered plus another 500 cc's of intravenous fluids.

The patient's intake and output record for 06/04/12 lacked documentation of these intravenous fluids the patient received. In addition, review of Patient #18's record reveal the following:

The patient's weights were documented as follows:

149 pounds on 06/02/12
156.1 pounds on 06/03/12,
173.2 pounds on 06/04/12
173.2 pounds on 06/05/12
166.3 pounds on 06/06/12
158 pounds on 06/07/12.

When the weight differences were questioned by the surveyor, on 06/07/12, another weight of the patient was requested. This weight was reported as 161.4 pounds.

Interview of Staff C, on 06/07/12 at 11:30 AM, revealed this patient is weighed by the night shift using a bed scale. Interview of Staff D at this time confirmed the weights documented for the patient were questionable.




03284


The medical record for Patient #26 was completed on 06/07/12 at 1:00 PM. The patient was admitted on 05/26/12 with diagnoses including pneumonia, congestive heart failure and elevated creatinine level. The patient received acute hemodialysis treatments in the dialysis unit three times a week beginning on 05/26/12.

Review of the dialysis treatment record revealed the weight prior to treatment was documented with no numbers and stated "weight not done-trapeze bar not removed on bed".

The pre-treatment weights noted in the dialysis clinical records were as follows:
201.4 pounds on 05/27/12,
200.9 pounds on 05/28/12,
200.1 pounds on 05/29/12, and
200.4 pounds on 05/30/12.
222.3 pounds on 05/31,
222.7 pounds on 06/01/12,
221.7 pounds on 06/03/12,
223 pounds on 06/05/12,
194.4 pounds on 06/06/12 and
221.4 pounds on 06/07/12.

The medical record lacked documentation to indicate the variation in weights were verified by the nursing .

The medical record indicated the amount of fluid removed by the dialysis treatment but lacked documentation of the post dialysis treatment weight for the following dates:

05/31/12 1300 litters removed,
06/01/12 2312 milliliters removed
06/05/12 1200 milliliters removed.

Staff G, (RN charge nurse ), during an interview on 06/07/12 at 1:30 PM, stated it was not acceptable practice to document the amount of fluid removed instead of the patient's post treatment weights. There was no documentation to indicate the registered nurse had evaluated the weights for this patient.


The medical record review for Patient #25 was completed on 06/07/12. The patient was admitted on 05/05/12 with a diagnosis of wound dehiscence with an abdominal wound vacuum (vac) device in place as a result of a previous surgery prior to this admission. The medical record lacked documentation of the measurement of this wound at the time of admission. The wound vac was changed every three days or as needed. The medical record lacked documentation of measurements of this wound at the time the wound vacuum was changed.

Staff O, Director of Nursing of critical care and the medical surgical unit, and Staff P, Charge Nurse on 3 North, confirmed these findings during an interview on 06/07/12 at 1:20 PM.

The wound nurse/ostomy nurse, during an interview on 06/08/12 at 10:30 AM, said it is expected the wound would be measured.

NURSING CARE PLAN

Tag No.: A0396

Based on medical record review and staff interview the facility failed to ensure care plans were developed for two (Patient #s 27 and 25) of two patients with wounds from a sample of 31 patients reviewed. The facility census was 105.

Findings include:

The medical record of Patient # 27 was reviewed on 06/07/12, and revealed this patient had been an inpatient from 05/26- 05/31/12. The patient had been admitted from a nursing home with a diagnosis of deep vein thrombosis and a history of a recent hip surgery. The nursing assessment, dated 05/26/12, identified a stage two pressure sore on the tailbone area, the presence of a black area and a blister on the left heel. The assessment lacked documentation of measurements of the wound and of the black and blistered area on the left heel. A comment, documented on a wound record, dated 05/26/12, revealed the patient was admitted to the hospital with a stage two wound area on the tailbone that had no dressing", dressing put on until wound nurse can assess and write orders". There was no documentation of a wound assessment by the wound nurse until three days later on 05/29/12.

The wound care nurse's (Staff B) assessment and documentation written on a physician's progress note, dated 05/29/12, revealed documentation of one measurement of the left heel, as 2 centimeters by 3.5 centimeters in size. There was no documentation of a measurement or mention of the tailbone wound. The medical record lacked documentation of measurements of the patient's tailbone wound for the five days the patient was an inpatient. There was no measurable way for the nurse to determine, at the time the patient was discharged, if the patient's wounds had deteriorated or improved.

Staff E confirmed this finding during an interview on 06/07/12 at 4:00 PM.




The medical record review for Patient #25 was completed on 06/07/12. The patient was admitted on 05/05/12, with a diagnosis of wound dehiscence and with an abdominal wound vacuum device in place. The wound vacuum was in place as a result of a previous surgery prior to this admission.
The patient's nursing care plan lacked identification of the patient's wound and what care was required for this patient related to the abdominal wound.
.
Staff R (registered nurse for clinical documentation ) confirmed this finding on 06/08/12 at 10:30 AM.







07312

ADMINISTRATION OF DRUGS

Tag No.: A0405

Based on observation, review of hospital policy for administration of medications, and staff interview, the staff failed to ensure all drugs were administered by nursing in accordance with the approved medical staff policy and procedure (medication administration -positive identification of patients #24406). This affected one patient (#31) from the four patients observed during medication pass. The census was 105.

Findings include:

The facility policy #24406, "Medication Administration-Positive Identification stated: "There should be at least two patient identifiers (neither to be the patient's room number) used whenever administering medications or blood products. Acceptable identifiers may be the patient's name on the armband, an assigned identifying number (a medical record number, or billing number) , address, telephone number, Social Security number or other patient-specific identifier,. Bar coding that includes two or more patient-specific identifiers (but not a room number) will comply with this recommendation."

Observation of a medication pass was completed on the 1A unit 06/07/12 at 9:50AM. Staff Q (staff nurse) was observed preparing medications. This staff member stated, prior to the administration of the medications, it was expected to check the medication with the order, check the name and date of birth of the patient receiving the medication and to check the arm band of the patient. A tablet was administered to Patient #31 after the nurse identified the patient by calling the patient's room number and checking the order. The nurse failed to check the arm band of the patient as per facility policy and as stated by Staff Q.

PHYSICAL ENVIRONMENT

Tag No.: A0700

Based on observations, staff interviews, and review of the hospital's generator inspection reports, the Condition of Participation of Physical Environment is not met as the facility failed to maintain the hospital environment related to corridor door with gaps and/or the doors failed to latch, the fire doors failed to close and latch, there were penetrations observed in the smoke barrier, the soiled utility room lacked an automatic closing device, an exit door failed to open, the exit lacked discharge lights, to ensure the smoke detectors were not located to air handler outlets, the sprinkler heads were clean, to ensure oxygen was appropriately stored, and to conduct weekly generator inspections. This had the potential to affect all patients. The census at the time of the survey was 105 patients.

Findings include:

A tour was conducted between 06/04/12 to 06/08/12, with Staff I, J, K, L, and M. Observations were made during the tour revealed the facility had failed to maintain the hospital environment related to corridor door with gaps and/or the doors failed to latch, the fire doors failed to close and latch, there were penetrations observed in the smoke barrier, the soiled utility room lacked an automatic closing device, an exit door failed to open, the exit lacked discharge lights, to ensure the smoke detectors were not located to air handler outlets, the sprinkler heads were clean, to ensure oxygen was appropriately stored, and to conduct weekly generator inspections. aforementioned areas of concern were observed and verified by staff during this tour. Refer to A709.

LIFE SAFETY FROM FIRE

Tag No.: A0709

Based on observations, staff interviews, and review of the hospital's generator inspection reports, the facility failed to ensure the Life Safety from fire requirements were met, related to corridor door gaps and/or failed to latch, fire doors failed to close and latch, smoke barrier penetrations, soiled utility room lacked an automatic closing device, exit door failed to open, exit discharge lights, smoke detector locations, dirty sprinkler heads, oxygen storage, and weekly generator inspections. This has the potential to affect all patients. The census at the time of the survey was 105 patients.

Findings include:

A tour was conducted between 06/04/12 to 06/08/12, the facility failed to maintain the hospital environment related to corridor door with gaps and/or the doors failed to latch, the fire doors failed to close and latch, there were penetrations observed in the smoke barrier, the soiled utility room lacked an automatic closing device, an exit door failed to open, the exit lacked discharge lights, to ensure the smoke detectors were not located to air handler outlets, the sprinkler heads were clean, to ensure oxygen was appropriately stored, and to conduct weekly generator inspections. The areas of concern were observed and verified by staff during this tour. Refer to A710.

LIFE SAFETY FROM FIRE

Tag No.: A0710

Based on observations, staff interviews, and the hospital's generator inspection logs, the facility failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association, NFPA 101, 2000 edition of the Life Safety Code. This was related to corridor door gaps and/or failed to latch, fire doors failed to close and latch, smoke barrier penetrations, soiled utility room lacked an automatic closing device, exit door failed to open, exit discharge lights, smoke detector locations, dirty sprinkler heads, oxygen storage, and weekly generator inspections. This has the potential to affect all patients. The census at the time of the survey was 105 patients.

Findings include:

A tour was conducted in the facility on 06/04/12 through 06/12/12, between 8:00 AM and 5:00 PM with Staff H, I, J, K, L, and M. The following areas were observed and verified with Staff H and I:

Corridor doors were observed with vertical gaps greater than 1/8 inch between the door sections, or failed to latch into the frame. Refer to K18.

Fire doors failed to close and latch into the frame when released from the hold open devices. Refer to K21.

Smoke barriers were observed with penetrations inside and around conduit and wires. Refer to K25.

One soiled utility room lacked an automatic closing device. Refer to K29.

One exit door failed to open when tested. Refer to K38.

Exit discharges were observed without lighting or with only one source of light. Refer to K45.

Smoke detectors were located less than 36 inches from air supply/return diffusers. Refer to K52.

The facility was observed with dirty sprinkler heads. Refer to K62.

Oxygen was observed not stored in a safe manner. Refer to K76.

There was no evidence of weekly generator inspection reports for 4 of 4 generators. Refer to K144.