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Based on medical record review, facility policy review, and staff interview, the facility failed to ensure nursing care was supervised and evaluated for one of ten patients reviewed (Patient #8). This could affect all patients receiving services from the facility.

Findings include:

1. The medical record of Patient #8 revealed the patient presented to the Emergency Department on 08/17/2020 at 12:21 PM with complaints of bilateral lower extremity edema and shortness of breath for two weeks. An Emergency Department's History and Physical (H&P) noted the patient had a past medical history of dementia, diabetes mellitus, atrial fibrillation, hypertension, and coronary artery disease. The H&P stated the patient had difficulty with instrumental activities of daily living (IADL) and remembering medications due to his/her worsening dementia. It was further noted that the patient was confused about the date and year of admission; however, family members informed staff this was baseline for the patient. The patient was admitted to the facility with a diagnosis of diastolic heart failure exacerbation and transferred to Medical Observation on 08/17/2020 at 4:15 PM.

A staff nurse's skin assessment at 5:08 PM revealed the epidermis was thin with a loss of subcutaneous tissue. The Braden Scale (a tool that predicted the risk for pressure ulcer development) was also assessed as required by facility policy. The score was 18, a mild risk for a pressure ulcer.

The patient was transferred to the facility's Medical Cardiology unit on 08/18/2020 at 8:59 PM for telemetry monitoring after ventricular tachycardia was noted. The Braden Scale was used to assess the patient's risk for a pressure ulcer at 9:10 PM on 08/18/2020 and once every 12 hour shift on 08/19/2020 and 08/20/2020. The scores were 18 and 19 indicating the patient was a mild risk for a pressure ulcer. The medical record lacked documentation staff nurses assessed the patient for the risk of pressure ulcer using the Braden scale on 08/21/2020 as required by facility policy. The patient was discharged home at 5:24 PM.

The facility policy titled, Wound Care Including Dressings, Negative Pressure Wound Therapy (NPWT), Removal of Drains, Packing and Pressure Injury Care Including Prevention, issued on 12/01/16, was reviewed on 09/14/2020 at 3:10 PM. According to the policy, registered nurses are responsible for utilizing a Pressure Injury Risk Assessment (i.e., the Braden Scale) to determine and monitor patient risk for pressure injury development within 24 hours of admission and daily and with change in level of care. The Braden Pressure Injury Risk Assessment is used to identify and monitor patients at risk for all patient populations including Behavioral Health and Women's Health if patient is mainly confined to bed or wheelchair. The policy further instructs registered nurses that dressing changes will occur three times weekly or as otherwise ordered. The wound will be measured on admission and weekly, or with any significant change.

Staff Z and Staff Y were interviewed on 09/14/2020 at 1:30 PM. Staff Z revealed that all registered nurses were required to assess patient's risk for pressure injury using the Braden Pressure Injury Risk Assessment every shift. It was confirmed, that on 08/21/2020, the day the patient was discharged home (the patient was discharged at 5:24 PM), the medical record lacked documentation any assessment for pressure injury using the Braden Scale was performed.

2. Review of Patient #8's medical record revealed the patient was transported via EMS to the Emergency Department again, on 08/22/2020 at 9:49 PM, after a fall at home and also worsening confusion. A Triage nurse's note stated EMS reported that the patient had a blood sugar of 36 earlier that day but patient didn't go to the hospital at that time as his/her blood sugar had improved to 140. The note further stated EMS reported the patient was "significantly more confused" since earlier that day. The note revealed the patient fell out of bed but did not hit his/her head. It was noted the patient was oriented only to self.

A nurse's note composed by an Emergency Department registered nurse on 08/22/2020 at 10:11 PM stated the patient had redness and "skin breakdown" to bottom area. It was noted that the wound was cleansed at this time. The patient was admitted to the facility's Neuro/Spine unit on 08/23/2020 at 6:22 AM. Documentation of a head to toe assessment at 6:30 AM revealed two skin tears to the patient's left forearm, one skin tear to the right forearm, and a wound to the patient's coccyx.

Further record review revealed the wound nurse was at the bedside of the patient on 08/26/2020 at 2:30 PM to assess wounds. An order was placed for staff to apply ZGuard barrier cream in a thin layer to affected area on the coccyx twice daily and as needed after cleansing. Orders were also placed for staff nurses not to change dressings on the patient's forearms and at 4:10 PM on 08/26/2020 it was ordered that staff should turn the patient every two hours during the day.

At 4:20 PM on 08/26/2020 the patient was noted to be resting in bed. The medical record lacked documentation the patient was turned. At 5:07 PM nursing staff documented only that the patient was "able to turn self." Again, at 5:40 PM staff noted the patient was able to turn him/herself. The medical record lacked documentation staff assisting the patient in turning as ordered. On 08/27/2020 at 9:20 AM, 11:37 AM, and 1:17 PM the patient was noted to be able to turn self. Again, the medical record lacked documentation staff assisted the patient to turn, reminded the patient to turn, or identified the position of the patient in order to ensure frequent repositioning.

These findings were confirmed with Staff Z in an interview on 09/16/2020 at 4:50 PM.

3. Radiographic imaging during Patient #8's second admission revealed moderate-sized right knee joint effusion (water on the knee) and acute 40% compression fracture of the right superior L2 endplate. According to a physician's H&P, the patient complained of low back pain at the beginning of the previous week, prior to the fall.

The physician ordered for nursing staff to medicate the patient with Acetaminophen 650 milligrams (mg) as needed for pain. Despite a physician progress note describing the patient's complaints of right hip and knee pain on 08/24/2020 at 6:21 AM, a nurse documented the patient rated his/her pain a 0 on a 0-10 scale at this time. The patient reported that his/her pain goal was 0. At 6:25 AM on 08/25/2020 the patient rated his/her pain a 10 on a 0-10 scale. The medication administration record (MAR) revealed the patient was medicated with Acetaminophen 650 mg as ordered. The medical record revealed the patient's pain was not reassessed until 4:25 PM. At 7:57 PM on 08/25/2020, a nurse documented the patient reported no pain (0 on 0-10 pain scale). The patient, however, was medicated with 650 mg of Acetaminophen at this time. The patient's pain was not reassessed until 8:00 AM on 08/26/2020. On 08/28/2020 at 8:16 PM the patient reported severe right knee pain rating it a 10 on a 0-10 scale. The patient was medicated with Acetaminophen 650 mg. Again, the patient's pain was not reassessed until 10:08 PM. His/Her pain remained severe as he/she rated it an 8 on a 0-10 scale. The patient's pain at 5:51 AM on 08/29/2020 was a 10 on a 0-10 scale. The patient was medicated with Acetaminophen. The reassessment of the patient's pain occurred two hours later, at 7:45 AM.

The facility policy titled, Pain Management, effective 07/19/19, was reviewed on 09/10/2020 at 5:00 PM. According to the policy, nursing staff are instructed to reassess and document after each pain management intervention in a timely and comprehensive manner appropriate to the circumstances. For pharmacological pain interventions, reassess the patient for the pain intensity and side effects once sufficient time has elapsed to reach peak effect dependent on the medication and route of administration.

These findings were confirmed with Staff Y and Staff Z during an interview on 09/10/20 at 5:15 PM.

4. Review of Patient #8's medical record from the first admission revealed a physician order for Lovenox (an anticoagulant medication used to prevent deep vein thrombosis and pulmonary embolism) 40 mg subcutaneous daily on 08/18/2020 at 3:45 PM. The order also instructed staff to administer the medication in the patient's abdomen. Nursing staff were ordered to notify the physician if the patient refused the medication.

The MAR revealed the attempt to administer the first dose occurred on 08/18/2020 at 4:00 PM; however, patient/family refused and the medication was not administered. The medical record lacked documentation a physician was notified of the refusal as ordered.

Review of Patient #8's medical record for the second admission revealed a physician order for Heparin (an anticoagulant blood thinner that prevents the formation of blood clots) 5000 units subcutaneous every 8 hours on 08/23/2020 at 7:50 AM. This order also instructed nurses to notify a physician if the patient refused.

The MAR revealed the patient refused the medication on 08/23/2020 at 8:30 AM, 08/23/2020 at 1:49 PM, 08/24/2020 at 4:45 PM, 08/26/2020 at 2:00 PM, and 08/27/2020 at 2:00 PM. The medical record lacked documentation a physician was notified of the refusals.

These findings were confirmed with Staff Y and Staff Z on 09/10/20 at 04:00 PM.

This deficiency substantiates Substantial Allegation OH00115517.