HospitalInspections.org

A. Based on document review and interview, it was determined for 3 of 3 clinical records reviewed (Pts. #1 - 3), the Hospital failed to ensure patients were turned every 2 hours to reduce skin breakdown.

Findings include:

1. On 3/3/16 at 11:55 AM, Hospital policy #PCS 372, titled, "Skin Care Prevention Protocol", revised 10/2015, was reviewed. The policy required, "Procedure: A. The Skin Risk Assessment (Braden Scale) is completed by the staff RN on patient admission and every Wednesday thereafter... a score of 18 or below indicates risk... B. If patient is at risk... 1. Reposition patient every 2 hours..."

2. On 3/1/16 at 1:00 PM, Pt. #1's clinical record was reviewed. Pt. #1 was a 67 year old male, admitted on 10/13/15, with diagnoses of chronic respiratory failure, end stage renal disease, diabetes mellitus, hypertension, hyperlipidemia, peripheral vascular disease, multiple decubitus ulcers, malnutrition, and encephalopathy. Pt. #1's history and physical dated 10/13/15, included, Pt. #1 came from an acute care hospital with mental status changes due to sepsis and still had pseudomonas on arrival. Pt. #1 was unable to move independently and required turning.

3. Pt. #1's turning documentation was reviewed for 3 weekends: January 16 - 17, 2016; January 23 - 24, 2016; and January 30 - 31, 2016. There are 2 shifts per day, each 12 hours in length - 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM. Two hour turning documentation was missing for the following dates and times:

- 1/17/16 10:00 AM - 12:00 PM, 2 hours
- 1/17/16 2:00 PM - 4:00 PM, 2 hours
- 1/31/16 10:00 AM - 12:00 PM, 2 hours
- 1/31/16 2:00 PM - 4:00 PM, 2 hours

4. On 1/23/16, the turning times were written incorrectly on the 7:00 PM to 7:00 AM shift, i.e. 8:00 AM to 10:00 AM, instead of 8:00 PM to 10:00 PM.

5. On 3/2/16, at approximately 3:00 PM, an interview was conducted with the Chief Quality Officer (E #1). E #1 stated the Patient Care Technician who recorded Pt. #1's turning on 1/23/16, was a day shift employee who worked overtime and did not use military time, causing the wrong times to be documented.

6. On 3/3/16 at 12:00 PM, Pt. #2's clinical record was reviewed. Pt. #2 was a 66 year old male, admitted on 2/6/16, with diagnoses of acute and chronic respiratory failure with hypercapnia. Pt. #2's Braden Scale was 12 on 2/19/16, requiring turning every 2 hours.

7. Pt. #2's turning documentation was reviewed for 2 weekends: February 20 - 21, 2016 and February 27 - 28, 2016. Two hour turning documentation was missing for the following time periods:

- 2/20/16 4:00 AM - 7:00 PM, 15 hours
- 2/21/16 7:00 AM - 7:00 PM, 14 hours
- 2/26/16 12:00 AM - 2:00 AM, 2 hours
- 2/26/16 4:00 AM - 6:00 AM, 2 hours
- 2/27/16 10:00 AM - 4:00 PM, 6 hours
- 2/28/16 10:00 AM - 4:00 PM, 6 hours

8. On 3/3/16 at 12:45 PM, Pt. #3's clinical record was reviewed. Pt. #3 was an 66 year old female, admitted on 1/14/16, with a diagnosis of acute post procedural respiratory failure. Pt. #3's Braden Scale was 13 on 2/18/16, requiring turning every 2 hours.

9. Pt. #3's turning documentation was reviewed for 2 weekends: February 20 - 21, 2016 and February 27 - 28, 2016. Two hour turning documentation was missing for the following dates and times:

- 2/19/16 8:00 PM - 10:00 PM, 2 hours
- 2/20/16 12:00 AM - 2:00 AM, 2 hours
- 2/20/16 4:00 AM - 8:00 AM, 4 hours
- 2/20/16 8:00 PM - 10:00 PM, 2 hours
- 2/21/16 12:00 AM - 8:00 AM, 8 hours
- 2/27/16 8:00 PM - 2/28/16 2:00 AM, 6 hours

10. On 3/3/16 at approximately 11:00 AM, an interview was conducted with the Quality Coordinator (E #2). E #2 stated all patients should be turned every 2 hours.

11. On 3/3/16 at 2:30 PM, an interview was conducted with the Chief Quality Officer (E #1). E #1 stated a problem with turning documentation was detected during the survey.

B. Based on document review and interview, it was determined for 1 of 10 clinical records reviewed (Pt. #1), of patients requiring suctioning, the Hospital failed to ensure patients who required suctioning, were suctioned as frequently as a physician ordered.

Findings include:

1. On 3/3/16 at 1:05 AM, Hospital policy #PCS 451, titled, "Suctioning, Tracheal Lavage, and Manual Hyperinflation", revised 2/2011, was reviewed. The policy required, "All tracheal suctioning is considered a sterile procedure. Tracheal suctioning may be performed by trained respiratory care practioners (primary responsibility) and registered nurses (back up). Repaying suctioning is a non-sterile procedure and may be preformed by trained RNs, PCTs, patient and family members." The policy did not include a doctor's order was required for suctioning.

2. On 3/1/16 at 1:00 PM, Pt. #1's clinical record was reviewed. Pt. #1 was a 67 year old male, admitted on 10/13/15, with diagnoses of chronic respiratory failure, end stage renal disease, diabetes mellitus, hypertension, hyperlipidemia, peripheral vascular disease, multiple decubitus ulcers, malnutrition, and encephalopathy. Pt. #1's history and physical dated 10/13/15, included, Pt. #1 came from an acute care hospital with mental status changes due to sepsis and still had pseudomonas on arrival. Pt. #1 also came with a percutaneous endoscopic gastrostomy (PEG) tube for feeding, a tracheostomy, and was ventilator dependent.

3. Pt. #1's physician's orders dated 10/13/15 at 8:30 PM, included suctioning every shift and when necessary. Pt. #1's respiratory notes on the 1/24/16 7:00 AM to 7:00 PM shift, lacked documentation of suctioning for the whole shift.

4. On 3/3/16 at 8:50 AM, an interview was conducted with the Director of Respiratory Therapy (E #7). E #7 stated suctioning is delivered according to a physician's order, unless emergency suctioning is required. E #7 stated she believed Pt. #1's suction had been done on the 1/24/16 7:00 AM to 7:00 PM shift, but the Respiratory Therapist did not document it.