HospitalInspections.org

Based on record review, interview, and observation, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for patients' care needs and/or health conditions with accepted standards of nursing care and/or according to hospital policy for 3 of 11 patients (Patients # 18, #19, #20).

1) Although nursing had noticed changes in Patient #18's lower legs' skin color and a dark spot on one of his toes on 09/11/17, it failed to assess, intervene, and evaluate the skin alterations for the following 72 hours until surveyor inquiry.

2) Patient #19's was admitted with known medical conditions that included Hypertension (high blood pressure). Patient #19's Stage 1 and/or Stage 2 Hypertension were not reassessed by nursing staff for up to 24 hours.

3) In spite of hospital personnel's staff awareness of Patient #20's need of assistance with activities of daily living (ADLs) and medical diagnosis of Blindness on admission, nursing failed to assess the patient's needs, implement interventions to address the patient's barriers and limitations, and evaluated care.



Findings include:

1) Patient #18 was surveyor observed in the hospital's day room on 09/14/17, at 1055. The patient was barefoot and sat in a wheel-chair. Patient #18's feet and lower legs were dusky colored. The patient's second toe on his left foot had a dark red colored blister approximately 1.5 centimeter (cm) in diameter.

Upon surveyor inquiry, Hospital Personnel #14 denied awareness of the blister during an interview on 09/14/17, at approximately 1115.

Record review of Patient #18's Daily Nurse Assessment Note dated 09/11/17 at 1300 reflected the patient's lower legs were "dusky...dark spot on left second toe..."

Patient #18's Daily Nurse Assessment Notes dated 09/11/17, at 2000, 09/12/17, at 1255, 09/12/17, at 2000, 09/13/17, at 1240, and 09/13/17, at 2000, did not reflect a wound assessment on Patient #18's left foot.

Hospital Personnel #13 observed and acknowledged the above findings on 09/14/17, at 1125.

Hospital Policy titled Assessment Guidelines dated 02/01/17 reflected that registered nurses completed patients' skin assessments "once per shift."



2) Record review of Patient #19's Complete Inpatient Evaluation dated 08/11/17, at 1027, reflected the patient's medical history that included Hypertension (high blood pressure).

Patient #19 Graphic Record Flow sheet dated 09/01/17, at 1900, reflected the patient's blood pressure of 152/92 mm Hg. There was no evidence that the patient's blood pressure was reassessed until 24 hours later, on 09/02/17, at 1900.

The Graphic Record Flow Sheet dated 09/02/17, at 1900, reflected Patient #19 had a blood pressure of 162/97 mm Hg. There was no documented evidence of a blood pressure recheck that day. The document dated 09/03/17, at 0645, reflected Patient #19's blood pressure of 143/72 mm Hg.

During an interview on 09/14/17, at 1315, Hospital Personnel #11 acknowledged the above findings.

Hospital Policy titled Assessment Guidelines dated 02/01/17 reflected for staff "to provide a comprehensive assessment and reassessment of the patient's bio-psycho-social needs...that clinically appropriate interventions can be designed and carried out in a manner that supports recovery."

The American Heart Association (2017) provided guidance that a blood pressure of 152/92 mm Hg was considered Hypertension Stage 1, and a blood pressure of 162/97 mm Hg was a Hypertension Stage 2
(http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/KnowYourNumbers/Understanding-Blood-Pressure-Readings_UCM_301764_Article.jsp#.WcQX4U2FOpo)

3) Patient #20's Comprehensive Integrated Assessment dated 10/11/6, at 1745, reflected the patient had been admitted for suicidal ideation. The patient's medical diagnoses included Blindness. He needed assistance with activities of daily living, including toileting.

Vital Signs and I&O (Intake and Output) documentation dated 10/11/16 through 10/19/16 reflected the patient did not have a bowel movement.

Vital Signs and I&O documentation dated 10/17/16, Patient #20 was noted to not have eaten anything and did not urinate at all. There was no evidence that nursing staff assessed the patient for nutrition- and/or elimination-related changes.

Daily Nurse Notes dated 10/11/16 through 10/20/16 did not reflect nursing assessments, assistive interventions, and/or evaluations of care that addressed Patient #20's limitations and barriers due to his blindness.

During an interview on 09/14/17, at 0910, Hospital Personnel #13 reviewed Patient #20's chart and acknowledged the above findings.

The Texas Board of Nursing (2013) noted that registered nurse scope of practice involved "the observation, assessment, intervention, evaluation, rehabilitation, care and counsel, or health teachings of a person who is ill, injured, infirm, or experiencing a change in normal health processes..." (http://www.bne.state.tx.us/practice_scope_of_practice_rn.asp)