HospitalInspections.org

Based on review of hospital documents and interviews with hospital staff, the hospital failed to ensure the registered nurse (RN) assessed, reassessed and evaluated the nursing needs and care for each patient. This occurred in ten of (# 6, 9, 11, 12, 15, 16, 18, 21, 22 and 23) twenty-two patient medical records reviewed.

Findings:

Review of a hospital policy titled, "Patient Assessment Reassessment", dated 10/2014, documented, "...Reassessment of the patient shall be performed at regular intervals in the course of care by medical and nursing staff....Reassessment shall take place when there is a significant change in the patient's condition or change in diagnosis..."

On 10/22/2015 at 12:45 p.m., Staff B stated the nursing staff were responsible for treating Stage I and II pressure ulcers. Pressure ulcers Stage III and greater were treated by the physical therapy (PT) department.

On 10/26/2015 at 1: 15 p.m., Staff GG stated skin assessments are performed every shift (12 hour shifts 7a and 7p) and every four hours in the intensive care unit (ICU).

Surveyors reviewed 22 medical records on the afternoon of 10/26/2015 with hospital clinical staff. Medical records # 6, 9, 11, 12, 15, 16, 18, 21, 22 and 23 contained documentation for wounds.

~The skin assessments documentation in EMR were inconsistent with the descriptions of the wounds.
~The skin assessments documentation varied from one nurse to another.
~The skin assessments did not include wounds previously identified

On 10/23/2015, Staff A stated pressure ulcers were not tracked and trended through the hospital's quality assessment and performance improvement (QAPI) program.

Based on record review and interviews with hospital staff, the hospital did not ensure medication errors identified by the hospital are analyzed and tracked in the hospital's quality assessment and performance improvement (QAPI) program.

Findings:

On 10/22/2015, surveyors conducted a tour of the hospital between 11:00 a.m. and 1:00 p.m.

Surveyors requested and reviewed the hospital's Pharmacy and Therapeutics (P and T) committee meeting minutes from January 2015 to present.

The P and T meeting minutes did not contain evidence that medication errors and adverse drug events were tracked and trended.

On 12/23/2015 at 10:00 a.m., Staff A was asked if medication errors and adverse drug events were tracked and trended thorough QAPI. Staff A stated, "No".