HospitalInspections.org

Based on observation, staff interview, medical record review, and review of policies and procedures, the hospital failed to ensure physician's orders were followed regarding the application of sequential compression devices. The hospital also failed to ensure nursing staff provided necessary assessment, monitoring, and nursing measures for pain management (refer to A395). The cumulative effect of these failures was a determination that the Nursing Services Condition of Participation was not met.

Based on staff interview, medical record review, and review of policies and procedures, the facility failed to ensure the sequential compression devices (SCDs) were applied and monitored according to the physician's orders for 1 of 2 sample patients (#1) identified at risk for development of a deep vein thrombosis (DVT) and for 1 of 1 sample patient (#5) who was not identified as high risk but had physician's orders for SCDs after being in a motorcycle accident. In addition, the facility lacked evidence nursing staff provided the necessary assessments, monitoring, and nursing measures to ensure adequate pain management for 1 (#5) of 4 sample patients who had pain. The findings were:

In regard to SCDs:

1. Review of the 8/29/12 admission history and physical (H & P) for patient #1 showed s/he was admitted with diagnoses including subdural hematoma. Review of the 8/29/12 nursing notes timed at 9:40 PM showed the patient was at high risk for development of a DVT. Review of the 8/29/12 physician's orders showed an order for SCD's to help in the prevention of developing a DVT. The following concerns were identified:
a. Observation on 8/30/12 at 2:38 PM showed a physical therapy staff member entered the patient's room to assist him/her with ambulation. Upon entrance into the room it was observed the patient had SCDs on both lower extremeties, however, the SCDs were not plugged into the pump and were therefore not working. The patient was assisted with ambulation until 3:10 PM at which time s/he returned to the room. At that point the therapist assisted the patient into the recliner. The SCDs were not placed on the patient's legs. Observation with a quality improvement staff member at 5 PM revealed the SCDs were still not placed on the patient's lower extremeties as ordered; the SCDs were off at least from 2:38 PM until 5 PM (2 hours and 22 minutes).
b. Interview with the manager of rehabilitation services on 8/31/12 at 9:34 AM revealed the patient had been transferred to the floor at 1:07 PM from the intensive care unit (ICU). Upon transfer from ICU, the SCDs were unplugged for transfer but were not plugged back in upon arrival to the telemetry floor. The manager further said when a patient was in the recliner, the usual practice by he and his staff was not to place the SCDs on because they could increase a patient's risk of falling. However, according to the Morse fall scale dated 8/29/12 at 9:40 PM, this patient was a low fall risk.
c. Interview with the telemetry unit nurse manager on 8/31/12 at 9:34 AM revealed she was unsure why the SCDs had not been plugged into the pump after transfer from the ICU to the telemetry floor the prior day (8/30/12). Review of the nursing documentation showed no evidence the SCDs were placed on the patient until 8:30 PM on the evening of 8/30/12, approximately 7 hours and 15 minutes after transfer from the ICU. Interview with the QAPI manager on 8/31/12 at 9:34 AM revealed nurses and therapist should have followed the physician's orders and the SCDs should have been placed on the patient and plugged in at all times when the patient was not ambulating.
d. According to "Clinical Nursing Skills" by Smith, Duell and Martin, Seventh Edition, 2008, pages 1022 through 1024, evidence based nursing practice SCDs "...are used to reduce risk of developing deep vein thrombosis by improving blood flow through the leg veins. The wraps must be used continuously (unless ambulating) in order to be effective. Interview with the QAPI manager on 8/31/12 at 9:34 AM revealed the hospital had adopted the "Clinical Nursing Skills" book as their nursing policies and procedures.

2. Review of the 8/30/12 admission H & P for patient #5 showed s/he was admitted following a motorcycle accident with diagnoses including a fourth grade laceration of the spleen. Review of the 8/30/12 physician's orders showed an order for SCD's and bedrest. The following concerns were identified:
a. Observation on 8/31/12 at 10:24 AM, accompanied by the QAPI manager, showed the patient was lying in bed and was not wearing the ordered SCDs. Interview with RN #1 on 8/31/12 at 10:40 AM revealed the patient was transferred from the intensive care unit to the surgical unit on 8/30/12 at 5:51 PM. Further interview with the RN revealed CNA #1 had removed the SCDs at 7:08 PM on 8/30/12 but that she did not know why. Review of the nursing documentation verified the SCDs were removed at 7:08 PM on 8/30/12. Continued review of the nursing documentation showed the SCDs remained off of the patient until 10:33 AM the next morning (8/31/12). Interview with the QAPI manager and RN #1 on 8/31/12 at 10:40 AM verified the SCDs remained off the patient for more than 15 hours continuously.
b. According to "Clinical Nursing Skills" by Smith, Duell and Martin, Seventh Edition, 2008, pages 1022 through 1024, evidence based nursing practice SCDs "...are used to reduce risk of developing deep vein thrombosis by improving blood flow through the leg veins. The wraps must be used continuously (unless ambulating) in order to be effective. Interview with the QAPI manager on 8/31/12 at 9:34 AM revealed the hospital had adopted the "Clinical Nursing Skills" book as their nursing policies and procedures. She further stated the patient should have had the SCDs on at all times according to the physician's order.

In regard to pain management:

Review of the 8/30/12 admission H & P for patient #5 showed s/he was admitted with diagnoses including grade four splenic laceration from a motorcycle accident. Review of physician's orders dated 8/30/12 showed an order for Morphine Sulfate 1 to 4 milligrams (mg) every one hour intravenously (IV) as needed for pain. The following concerns with patient management were identified:
a. Review of nursing documentation showed on 8/30/12 at 4 AM, the patient complained of abdominal pain rated 3 on a scale of 0 to 10 with 10 being the worst (3/10). Review of the patient's established pain goal for that day was less than three. Continued review of the nursing documentation showed on 8/30/12 at 6 AM, two hours later, the patient's pain level was increased to 4/10. The patient was then medicated, however, review of the re-assessment at 8:10 AM, showed the patient's pain remained at 4/10 and was a constant ache. Review of the 8/30/12 nursing documentation at 10:03 AM, now six hours after the pain started, showed the patient was re-assessed and his/her pain level was increased to 7/10 and was described as sharp, shooting, and stabbing in nature. The patient was again medicated and upon re-assessment two hours later, it was 0/10. It took approximately eight hours to resolve the patient's pain that began at 4 AM.
b. Review of the nursing documentation for 8/30/12 timed at 5:51 PM showed the patient had constant pain rated 6/10. Continued review showed his/her lights were dimmed, ice was applied and the patient was given emotional support and diversion. However, no pain medication was administered. The patient's pain was re-assessed at 7:41 PM and was again described as 6/10, no relief, and was constant. At this time, the patient was medicated and his/her pain was relieved. However, this patient's pain needs were not met for approximately two hours. Review of the care plan showed the patient's acceptable pain goal for that day was less than five.
c. Review of the daily care plans showed the patient's acceptable pain level goal varied from less than three to less than five. However, review of the nursing documentation showed the patient's pain varied from three to seven between 8/30/12 and 8/31/12. Interview with the QAPI manager on 8/31/12 at 10:40 AM verified the patient's pain goals should have been met.
d. Review of the facility's policy on pain management, revised August 2011, showed a patient's pain should be "...re-assessed in two hours or less...Respond to patient's request for pain relief as soon as possible. Excessive response time to control pain can increase pain level and decrease pain control effectiveness."

Based on observation, staff interview and medical record review, the hospital failed to ensure physical therapy staff followed physician's orders and national acceptable standards of practice for 1 of 6 sample patients (#1) who had rehabilitation treatment orders. The findings were:

1. Review of the 8/29/12 admission history and physical for patient #1 showed s/he was admitted with diagnoses including subdural hematoma. Review of the 8/29/12 nursing notes timed at 9:40 PM showed the patient was at high risk for development of a DVT. Review of the 8/29/12 physician's orders showed an order for SCD's to help in the prevention of developing a deep vein thrombosis (DVT). The following concerns were identified:
a. Observation on 8/30/12 at 2:38 PM showed a physical therapy staff member entered the patient's room to assist him/her with ambulation. Upon entrance into the room it was observed the patient had SCDs on both lower extremeties, however, the SCDs were not plugged into the pump and were therefore not working. The patient was assisted with ambulation until 3:10 PM at which time s/he returned to the room. At that point the therapist assisted the patient into the recliner. The SCDs were not placed on the patient's legs. Observation with a quality improvement staff member at 5 PM revealed the SCDs were still not placed on the patient's lower extremeties as ordered; the SCDs were off at least from 2:38 PM until 5 PM (2 hours and 22 minutes).
b. Interview with the manager of rehabilitation services on 8/31/12 at 9:34 AM revealed the patient had been transferred to the floor at 1:07 PM from the intensive care unit (ICU). Upon transfer from ICU, the SCDs were unplugged for transfer but were not plugged back in upon arrival to the telemetry floor. The manager further said when a patient was in the recliner, the usual practice by he and his staff was not to place the SCDs on because they could increase a patient's risk of falling. However, according to the Morse fall scale dated 8/29/12 at 9:40 PM, this patient was a low fall risk. Additionally, the rehabilitation manager stated he was unable to find a physical therapy policy and procedure or national physical therapy standards to support his therapists' practice of not re-applying SCDs while a patient was in the recliner. According to "Clinical Nursing Skills" by Smith, Duell and Martin, Seventh Edition, 2008, pages 1022 through 1024, evidence based nursing practice SCDs "...are used to reduce risk of developing deep vein thrombosis by improving blood flow through the leg veins. The wraps must be used continuously (unless ambulating) in order to be effective. Interview with the QAPI manager on 8/31/12 at 9:34 AM revealed the hospital had adopted the "Clinical Nursing Skills" book as their nursing policies and procedures.