HospitalInspections.org

Based on review of clinical records and interview it was determined the Facility failed to assure chemical restraints were not ordered PRN (as needed) for 13 (#1-#12 and #14) of 15 (#1-#15) patients. Failure to assure chemical restraints were not ordered PRN did not assure patients' behavior was managed by physician order and not at the discretion or convenience of a nurse. This failed practice was likely to affect all patients admitted to the Facility. Findings follow:

A. Review of routine orders, "Physician Admission Orders" for Patients #1-#12 and #14 revealed Haldol 2 mg (milligram) PO (by mouth)/IM (intramuscular) PRN onset of psychotic unsafe behavior, may repeat every 2 hr (hour) if needed, not to exceed 8 mg in 24 hrs.

B. Findings were confirmed with the Director of Senior Care on 09/17/14 during interview at 1400.

Based on review of clinical records, review of Patient Handbook Senior Care Center, review of Senior Care Tech (Technician) Daily Flow Sheets and interview, it was determined the nursing staff failed to assure patients were bathed according to protocol for 14 (#1-#12, #14-#15) of 15 (#1-#15) patients. The failed practice did not assure personal hygiene was maintained and was likely to cause skin breakdown, infections, decreased dignity and self-esteem. This failed practice was likely to affect all patients admitted to the Unit. Findings follow:
A. Review of the Patient Handbook Senior Care Center on 09/17/14 revealed, patients were encouraged to bathe at least every other day or as needed. Assistance would be provided for you, should you require assistance with bathing or dressing.

B. During interview with Mental Health Technician (MHT) #1 on 09/17/14 at 0920, he stated baths were given every day. During interview with the Director of Senior Care on 09/17/14 at 1000, she confirmed the MHTs showered/bathed some patients every day as part of their daily duties but all the patients were not bathed on the same day. Baths were to be recorded on the MHT's Daily Flow Sheets. The Director of Senior Care presented Senior Care Tech (Technician) Daily Flow Sheets dated 08/01/14 through 09/15/14 for review, explaining the Flow Sheets were not kept or included as a permanent part of the clinical record.

C. Review of the clinical records for Patients #1-#12, #14-#15 revealed no evidence showers or baths were given.

D. Review of Senior Care Tech Daily Flow Sheets from 08/01/14 through 09/16/14 revealed the following:
1) Patient #1 admitted 09/07/14, discharged 09/16/14 had no evidence of a bath on 09/08/14 or 09/12/04.
2) Patient #2 admitted 09/04/14, had not been discharged by time of survey had no evidence of a bath on 09/06/14, 09/08/14, 09/10/14, 09/12/14 and 09/14/14.
3) Patient #3 admitted 08/22/14, had not been discharged by time of survey had no evidence of a bath on 08/30/14, 09/02/14, 09/06/14, 09/10/14, 09/12/14 and 09/14/14.
4) Patient #4 admitted 09/09/14, had not been discharged by time of survey had no evidence of a bath on 09/13/14 and 09/15/14.
5) Patient #5 admitted 09/12/14, had not been discharged by time of survey had no evidence of a bath on 09/14/14.
6) Patient #6 admitted 09/11/14, had not been discharged by time of survey had no evidence of a bath on 09/15/14.
7) Patient #7 admitted 09/08/14, had not been discharged by time of survey had no evidence of a bath on 09/12/14 and 09/14/14.
8) Patient #10 admitted 07/27/14, discharged 08/08/14 had no evidence of a bath on 07/29/14, 07/31/14, 08/02/14 and 08/06/14.
9) Patient #11 admitted 08/28/14, discharged 09/10/14 had no evidence of a bath on 09/02/14, 09/04/14 and 09/08/14.
10) Patient #12 admitted 08/29/14, discharged 09/09/14 had no evidence of a bath on 08/31/14, 09/02/14 and 09/06/14;
E. Findings were confirmed with the Director of Senior Care on 09/18/14 during interview at 1110.

Based on review of policies and procedures, review of clinical records and interview, the Facility failed to assure skin integrity was included on the Plan of Care and failed to assure a Wound Care Nurse assessed patients' whose Braden Scale measured 18 or less for nine (#2-#6, #8-#9 and #14-#15) of 15 (#1-#15) patients. Failure to assure skin integrity was included on the Plan of Care and failure to assure patients were assessed by a Wound Care Nurse for patients with low Braden Scale scores placed them at a higher potential for skin breakdown and extended hospitalization. This failed practice was likely to affect all patients admitted to the Facility. Findings follow:

A. Review of Braden Scale: Skin Assessment for Patient #2 admitted 09/01/14 revealed Braden Scale scores of 16 and 17. Review of the clinical record revealed no evidence skin integrity was included on the Plan of Care and no evidence Patient #2 was assessed by a Wound Care Nurse.
B. Review of Braden Scale: Skin Assessment for Patient #3 admitted 08/22/14 revealed Braden Scale scores of 14, 16, 17 and 18. Review of the clinical record revealed no evidence skin integrity was included on the Plan of Care and no evidence Patient #3 was assessed by a Wound Care Nurse.
C. Review of Braden Scale: Skin Assessment for Patient #4 admitted 09/09/14 revealed Braden Scale scores of 15, 17 and 18. Review of the clinical record revealed no evidence skin integrity was included on the Plan of Care and no evidence Patient #4 was assessed by a Wound Care Nurse.
D. Review of Braden Scale: Skin Assessment for Patient #5 admitted 09/12/14 revealed Braden Scale scores of 14 and 18. Review of the clinical record revealed no evidence skin integrity was included on the Plan of Care and no evidence Patient #5 was assessed by a Wound Care Nurse.
E. Review of Braden Scale: Skin Assessment for Patient #6 admitted 09/11/14 revealed Braden Scale score of 18. Review of the clinical record revealed no evidence skin integrity was included on the Plan of Care and no evidence Patient #6 was assessed by a Wound Care Nurse.
F. Review of Braden Scale: Skin Assessment for Patient #8 admitted 09/14/14 revealed Braden Scale score of 18. Review of the clinical record revealed no evidence skin integrity was included on the Plan of Care and no evidence Patient #8 was assessed by a Wound Care Nurse.
G. Review of Braden Scale: Skin Assessment for Patient #9 admitted 07/03/14 revealed Braden Scale scores of 15, 16, 17 and 18. Review of the clinical record revealed no evidence skin integrity was included on the Plan of Care and no evidence Patient #9 was assessed by a Wound Care Nurse.
H. Review of Braden Scale: Skin Assessment for Patient #14 admitted 06/23/14 revealed Braden Scale scores of 13 and 18. Review of the clinical record revealed no evidence skin integrity was included on the Plan of Care and no evidence Patient #14 was assessed by a Wound Care Nurse.
I. Review of Braden Scale: Skin Assessment for Patient #15 admitted 06/25/14 revealed Braden Scale scores of 13, 14, 15, 16, 17 and 18. Review of the clinical record revealed no evidence skin integrity was included on the Plan of Care and no evidence Patient #15 was assessed by a Wound Care Nurse.
J. Review of policy, "Pressure Wound Decubitus Care" revealed Patients who have skin breakdown or have lower than 18 score on Braden scale will be referred to the Wound Care Nurse on admission or anytime the score becomes 18 or below or when breakdown is noted.
K. Review of Braden Scale: Skin Assessment revealed, "Score of 18 or less, any open or red pressure areas requires Skin Integrity Plan of Care".
L. Findings were confirmed with the Director of Senior Care on 09/18/14 during interview at 1015.