HospitalInspections.org

Based on record review and interviews it was determined the facility failed to ensure a consent was in place prior to the initiation of hemodialysis treatments for one [#4] of ten sampled medical records reviewed .

Findings included,

A review of patient #4's medical record specifically the physician's hemodialysis orders dated 10/24/17, hemodialysis treatment flow sheets and patient consent forms did not reveal a patient consent for hemodialysis.

On 10/31/2017 at 3:00 p.m. an interview with the VP of Quality/Patient Safety during the record review confirmed the above finding.

Based on record reviews, policy review and interview it was determined the facility failed to ensure restraints were released and repositioned every two hours for 1 (#2) of 10 sampled records reviewed.

Findings included,

A review of Patient #2's medical record revealed physician's orders for soft wrist restraints for patient safety due to pulling at and dislodging tubes. A review of the restraint documentation dated 10/29/17 showed the restraints were released and repositioned every two hours until 11:51 a.m. There was no documentation of the restraints being released and repositioned again until 8:00 p.m. The record documented the restraints released and repositioned at 8:00 p.m. and 10:00 p.m. There was no further documentation until 10/30/17 at 1:59 a.m. a four hour time span.

A review of the facility policy titled "Patient Restraint/Seclusion" stated a RN will assess the patient at least every two hours for signs of injury associated with restraint....needs for range of motion, exercise of limbs and systematic release of restrained limbs are being met.

On 10/31/2017 at 3:00 p.m. an interview with the VP of Quality/Patient Safety during record review confirmed restraint documentation should show every two hours assessments and confirmed the above findings did not follow policy.

Based on observation, record review and interviews it was determined the facility failed to have sufficient patient care staff to ensure patient care needs were met.

Findings included,

On 10/30/2017 at 10:00 a.m. accompanied by the VP of Quality/Patient Safety a tour of the 4 North patient care unit was conduced. At the time of the tour the unit had thirty-seven patients. It was staffed with seven registered nurses and two patient care technicians. An interview with the charge nurse stated "all patients required turning and repositioning and assistance with feeding. However there is not enough staff to accomplish".

Interview with an Agency Nurse at 10:40 a.m. stated "I am just starting my scheduled 9:00 a.m. medication pass". The Charge Nurse stated "medications have 1 hour before or 1 hour after scheduled time. The medications are considered late and the policy states to notify the patient's physician".

Interview with current patients [patient #4 and #5] revealed "it takes over an hour to have the call light answered and then the staff says they don't have time to get me up". Both patients stated it did not matter day or night, they get the same response from staff "can't get you up don't have time". Patient #4 stated "his bed has been changed twice, because I had a bowel movement in the bed, I just couldn't hold it any longer". The patient staff refused to get him up stating "didn't have time".

Interview on 10/31/2017 at 2:00 p.m. with the Nursing Supervisor revealed "we had a recent influx of patients over the weekend and staffing was not what it should be even though we have pulled in agency staffing".

The VP of Quality/Patient Safety confirmed the above findings.

Based on record review, policy and interview it was determined the facility failed to ensure medications were given appropriately to ensure the effectiveness of the medication for one (#7) of ten sampled records and failed to ensure Hemodialysis was administered per physician prescribed prescription for one (#4) of ten sampled records.

Findings included,

1. A review of Patient #7's medical record revealed a physician order for Calcium Acetate [PhosLo 667 mg (milligram) tablet, two tabs by mouth three times a day with meals. A review of the medication administration record [MAR] showed the medication was profiled as three times a day with meals at 8:00 a.m., 12:00 p.m. and 5:00 p.m.

An interview on 10/31/2017 at 3:00 p.m. with the Director of Food Services stated tray service to 4 North was at 8:00 a.m., 1:00 p.m. and 6:00 p.m.

A review of the MAR indicated the following:
09/22/2017 Calcium Acetate was given at 12:23 PM and 6:04 PM
09/23/2017 Calcium Acetate was given at 8:09 AM, 12:52 PM and 4:56 PM-not given with meal
09/24/2017 Calcium Acetate was given at 9:19 AM-not given with meal, 1:27 PM and 4:41 PM-not given with meal
09/25/2017 Calcium Acetate was given at 8:15 AM, 2:51 PM-not given with meal and 10:15 PM-not given -patient not available-no documentation if the patient received a dinner time meal.
09/26/2017 Calcium Acetate was given at 8:43 AM, 2:00 PM-tray late and 4:33 PM-not given with meal
09/27/2017 Calcium Acetate was given at 8:56 AM, 2:22 PM-not given with meal and 5:15 PM-not given-patient not available-no documentation if patient received a dinner time meal.
09/28/2017 Calcium Acetate was given at 8:42 AM, 1:35 PM the patient was discharged prior to meal service.
Documentation confirmed the patient did not receive then phosphate binder with meals for 6 out of 19 scheduled doses. Phosphate binders need to be taken with food to effectively bind with phosphate.

An interview on 10/31/2017 at 3:10 p.m. with the VP of Quality/Patient Safety confirmed the findings.

2. A review of Patient #4 Hemodialysis physician orders revealed Hemodialysis was ordered for three times per week on [MWF] Monday, Wednesday and Friday via AV Fistula, Duration 3 hours, blood flow rate [BFR] 400, dialysis flow rate [DFR] 600, Potassium [K] bath: 3K and Calcium [Ca] Bath of 2.5 Ca.

A review of the treatment flow sheets documented hemodialysis treatments was given on TTS [Tuesday, Thursday, Saturday]. There was no documentation why hemodialysis not given on physician prescribed days. Continued review of the treatment flow sheets documented the following:
On 10/24/2017 the BFR was at 350-no documentation why the BFR ran below the physician prescribed BFR of 400.
On 10/26/2017 the BFR fluctuated between 350 and 300-no documentation why the BFR ran below the physician prescribed BFR of 400. Potassium Bath [K] was set at 2K-no documentation why the potassium bath was below the physician prescribed 3K bath.
On 10/28/2017 the BFR was at 300-no documentation why the BFR ran below the physician prescribed BFR of 400. Calcium Bath [Ca] was set at 2Ca-no documentation why the calcium bath was below the physician prescribed 2.5Ca bath.
On 10/30/2017 the BFR was 350-no documentation why the BFR ran below the physician prescribed BFR of 400. Potassium Bath [K] was set at 2K-no documentation why potassium bath was below the physician prescribed 3K bath.

An interview on 10/31/2017 at 3:10 p.m. with the VP of Quality/Patient Safety confirmed the findings.