HospitalInspections.org

Based on interview and record review the facility failed to ensure that the governing body had direct consultation with the leader of the Medical Staff or the designee to discuss matters related to the quality of medical care provided to patients. The Governing body also failed to adopt policies and procedures to address how it would implement and evidence that the required consultations took place. This failure had the potential to affect the quality of care and safety of all patients. The facility census was 153.

Findings included:

1. Record review of the Medical Staff Bylaws and the Governing Body Board Meeting Minutes did not contain any evidence that there were scheduled direct consultations between the Governing Body and the leader of the Medical Staff.

2. During a telephone interview on 04/27/16 at 11:10 AM, Staff X, Chief Executive Officer (CEO), stated that there were no direct consultation meetings between the Governing Body and the leader of the Medical Staff. He stated that he was a member of the Governing Board but that he did not schedule one to one meetings with the head of the Medical Staff to discuss the quality of care to patients.

During an interview on 04/27/16 at 11:25 AM, Staff A, Chief Nursing Officer (CNO), stated, "We don't have a policy or procedure and it's not in the Bylaws, we are just straight up deficient". She stated that she contacted Staff B, Director of Accreditation and Licensing and Director of Quality Management, and he stated that he had read the regulation requirements and that there had been no provisions for periodic consultations throughout the year.

Based on observation, interview, record review, and policy review, the facility failed to individualize interventions and/or goals for four current patients (#7, #1, #2 and #14) of nine current patients and one discharged patient (#8) of one discharged patient care plans reviewed. These failures had the potential to affect all patients when their needs were not identified and interventions were not implemented which could lead to poor patient outcomes. The facility census was 153.

Findings included:

1. Record review of the facility policy titled, "Interdisciplinary Care Planning," showed that the Care Plan (section of medical record that contained goals and interventions entered by nurses and other staff that directed the care of the patient) should include:
- The patient's individual care needs;
- The patient's treatment goals and objectives;
- The patient's patient specific interventions;
- A review with patient/and or family every 24 hours.

2. Observation on 04/25/16 at 3:45 PM, showed Patient #7 awake, arms and legs contracted (muscle stiffness), with spontaneous movement but was not able to communicate.

3. Record review of Patient #7's History and Physical (H&P) showed he was a 26 year old male with a history of cerebral palsy (a disease that affected body movement and muscle coordination), awake but not able to follow commands.

Record review of Patient #7's care plan showed no problems, individualized goals and objectives, or interventions related to his communication needs.

During an interview on 04/25/16 at 3:50 PM Staff FF, Registered Nurse (RN), stated that Patient #7 could not push the nurse call button if he needed help, did not speak, and care providers had to use facial expressions to determine the patient's needs.

During an interview on 04/25/16 at 4:00 PM, Staff U, RN Educator, stated that Patient #7's communication needs should be included in the care plan but it had not been addressed. Staff U further stated that there was no documentation that a nurse had discussed how the patient's mother (his care provider at home) identified his needs, the best way to communicate with the patient, or the patient's care plan.

4. Record review of Patient #1's H&P showed that she was admitted on 4/21/16 with the following diagnoses:
- Acute congestive heart failure (a rapid onset condition in which the heart is unable to maintain adequate circulation of blood);
- Acute cardiogenic pulmonary edema (increased pressure in the heart); and
- Acute hypoxic respiratory failure (a condition where there is not enough oxygen reaching the tissues of the body caused by a failure of the respiratory system).

Record review of Patient #1's medication orders showed a preventive treatment of a blood thinner (Heparin, a high risk medication that can cause unwanted bleeding) and a medication used to prevent blood clots (Lovenox, another medication considered high risk for unwanted bleeding) by injection every 24 hours.

Record review of Patient #1's treatment orders showed:
- Change wound dressing every 72 hours and as needed for the patient's skin breakdown on her buttocks.
- Wound should be visualized and inspected every shift by gently peeling back dressing and reapply.
- Change dressing every three days until no longer at risk.
- Two times daily cleanse, irrigate and soak with soap and water the patient's abdomen.
- Apply medication powder to the abdomen daily.

Record review of Patient #1's care plan showed no individualized care plan problem that addressed a bleeding risk associated with use of his medications or interventions for specific areas of skin break down.

5. Record review of Patient #2's H&P showed he was admitted on 4/23/16 for:
- Congestive Heart Failure (CHF) exacerbation (worsening of condition in which the heart is unable to maintain adequate circulation of blood in the tissues of the body).
- Atrial Fibrillation (an abnormal heart rhythm characterized by rapid and irregular beating).
- Chronic Obstructive Pulmonary Disease (COPD, a lung disorder that persistently obstructs airflow).
- An implantable cardioverter-defibrillator (ICD, a battery-powered device placed under the skin that keeps track of the heart rate. Thin wires connect the ICD to the heart. If an abnormal heart rhythm is detected the device will deliver an electric shock to restore a normal heartbeat) in place.

Record review of Patient #2's medication orders showed that patient takes a blood thinner (Coumadin a high risk medication for unwanted bleeding) daily. The patient also had an order for, "Nothing by mouth" (NPO) after midnight for an ICD procedure the next morning.

Record review of Patient #2's care plan showed no individualized care plan problem addressing bleeding risk associated with use of the blood thinner and to reflect the presence of Patient #2's ICD.

During an interview on 4/25/16 at 3:25 PM, Staff O, RN, stated that the only blood thinner/blood clot prevention medications that she would care plan for high risk of unwanted bleeding would be something like a Heparin drip (medication continuously injected directly into the vein over a period of time). She stated that Patient #1's care plan should have specific skin risks included. Staff O stated that the presence of the ICD is an important part of Patient #2's medical history and should have been reflected on the patient's care plan given the patient's cardiac history. Staff O stated that care plans are updated every shift (12 hours) and should be updated before this shift is over to reflect the new order received for cardioversion (a medical procedure by which an abnormally fast heart rate (tachycardia) or cardiac arrhythmia is converted to a normal rhythm using electricity or drugs) procedure.

Record review of Patient's care plan on 4/26/16 at 2:00 PM showed that Patient #2's care plan had not been updated to reflect the ICD procedure.

6. During an interview on 04/26/16 at 3:35 PM, Patient #14, stated that she had a suprapubic catheter (a tube that is surgically inserted from the belly to the bladder to allow urine to drain from the body) and that nurses were changing the dressing daily,

During an interview on 04/26/16 at 4:10 PM, Staff P, RN, stated that Patient #14 cared for herself daily, including dressing changes.

During an interview on 04/26/16 at 4:15 PM and concurrent patient record (#14) review, Staff H, Director of Nursing, Behavioral Health Unit, acknowledged that:
- The patient was admitted on 04/20/16 with problems including suicidal risk (acts, threats, or thoughts to self harm), Diabetes, Type-One (a disease when the body cannot rid itself of excess glucose/sugar in the blood and requires insulin/hormone to control); and a kidney infection (a bacterial infection that travels from the urinary tract up to the kidneys requiring prompt medical attention); and she had been non-compliant with taking care of herself.
- The patient had a suprapubic catheter placed about three and one-half years ago.
- The care plan had no individualized goals or interventions related to care of the patient's suprapubic catheter site, and it should have.

7. Record review of discharged Patient #8's H&P showed she was a 65 year old female from a nursing home with a history of cerebral palsy and dementia (loss of memory). Physician noted that patient had significant psychiatric issues and could not give any medical history. Patient #8 was admitted on 04/22/16 and discharged on 04/25/16 at 2:00 PM.

Record review of nursing notes showed that Patient #8 was combative, aggressive, agitated, pulled out intravenous (IV-small tube placed into vein to give patient medicine or fluid) tube, unable to follow commands, and spit at care providers throughout her admission. Record did not show any attempt to contact nursing home or family to determine if this was the patient's normal condition.

Record review of Patient #8's care plan showed no individualized goals or interventions related to her communication needs or agitation.

During an interview on 04/25/16 at 4:15 PM, Staff U, RN Educator, stated that Patient #8's communication needs should have been included in the care plan but was not. Staff U further stated that there was no documentation of nurse communication with the nursing home, patient family, or primary care physician to determine if this was the patient's normal condition and identify appropriate care plan interventions.

During an interview on 04/25/16 at 4:30 PM Staff B, Director of Quality Management, stated that the facility was aware of issues related to care plans and a team has been assigned to make corrections.

During an interview on 04/27/16 at 1:05 PM, Staff A, Chief Nursing Officer, stated that care planning was a weak area and a focus for improvement. At present, there were multiple places to document and it made it harder for nurses to find the right location to enter a care plan.



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