HospitalInspections.org

Based on document review and interview, it was determined the LTACH (Long Term Acute Care Hospital) failed to ensure an appropriate number of staff were available to provide patient cares. This has the potential to affect all patients (average daily census of 24 patients) receiving cares.

Findings include:

1. The Daily Assignments and Census sheets dated 5/5/16 through 5/19/16 were reviewed on 6/7/16 at approximately 12:30 PM with E#4 (Interim Nurse Manager). E#4 stated the HAU (High Acuity Unit) staffing ratio is 1 nurse to 3 patients and the second and third floor are 1 nurse to 6 patients. The sheets noted the following staffing examples:

On 5/7/16, E#6 (House Supervisor) was assigned to a patient in the HAU due to a census of 7 and only 2 other nurses available.

On 5/8/16, the LTACH's patient census was 29 and was supervised by an Agency contracted nurse (E#5) who was also assigned to a patient in the HAU. During 7:00 PM to 11:00 PM, the House Supervisor (E#6) was assigned to 4 patients in the HAU.

2. During an interview on 6/7/16 at approximately 2:00 PM, E#1 (Director of Quality Management) stated "When the census increased to 28-30 patients (May 2016), we depended on agency staff. It is hard to keep staff because our census fluctuates so much we can't always offer the hours they (staff) want or need."

A. Based on document review and interview, it was determined the Hospital failed to ensure the nursing plan of care was revised, updated and followed. This was found in 10 of 10 (Pt. #4, #5, #6, #9, #1, #2, #3, #7, #8 and #10) records reviewed. This has the potential to affect all patients (average daily census of 24 patients) receiving cares.


Findings include:

1. The policy titled "Skin and Wound Care Program Overview" was reviewed on 6/7/16 at approximately 12:00 PM. The policy included ..."Components: Department Member Roles as to Related to Specific Discipline...Nursing...Directs the development and implementation of an individualized plan of care based on assessed needs...Documents and reports change of condition and revises plan of care as necessary.

2. Pt. #4 was admitted on 4/13/16 with a diagnosis of Disease of Stomach and Duodenum- unspecified. The clinical record was reviewed on 6/7/16 at approximately 12:15 PM. The record included the pt. had a coccyx wound with negative pressure wound therapy. The SN visit notes dated 5/4/16 at 22:25 (10:25 PM) and 5/6/16 at 0935 (9:35 AM) included the "negative pressure wound therapy appliance" assessment not done because it had been discontinued. The SN visit notes dated 5/6/16 at 0046 (12:46 AM) and 22:56 (10:56 PM) included an assessment of the "negative pressure wound therapy appliance. The physicians progress note dated 5/4/16 "Plan:..Hold the Veraflo (negative pressure wound therapy) and will start pt. on acetic acid, impregnated gauze pack.
During the interview with E#3 (Clinical Educator) on 6/8/16 at approximately 10:45 AM, it was stated "the physician removed the Negative pressure wound therapy on 5/4/16 and it wasn't there for the SN to assess on 5/6/16." It was also confirmed the plan of care wasn't updated.

Pt. #4 clinical record included a physician's order dated 5/4/16 for wound care: coccyx, cleanse wound with normal saline, apply acetic acid, apply gauze dressing and cover with dressing daily. The SN wound flow sheet dated 5/15/16 to 5/29/16, lacked daily wound care was done in 7 of 15 days.

3. Pt. #5 was admitted on 5/26/16 with diagnosis of Chronic Ulcer Lower Leg. The clinical record was reviewed on 6/8/16 at approximately 9:20 AM. The record included the pt. had a wound of the left chest, left lower leg and right lower leg. The physician's order dated 5/27/16 for wound care stated, left chest- cleanse with normal saline, apply Bacitracin and silicone foam dressing, left lower leg- cleanse with normal saline apply leptosperum honey, apply dressing with normal saline 4X4 over Medihoney then Kerlix, and for right lower leg and left lower leg- apply dresssing with tubigrips. The SN wound flow sheet dated 5/28/16 to 5/30/16, lacked daily wound care was done in 2 of 4 days.

4. Pt. #6 was admitted on 5/25/16 with diagnosis of Laceration Foreign Body of Buttocks. The clinical record was reviewed on 6/8/16 at approximately 11:00 AM. The record included the pt. had a left buttocks wound. The record included a physician's order dated 5/26/16 for wound care, left buttock- cleanse with normal saline, apply dakin's solution, 1/2 strength and apply dressing. The SN wound flow sheet dated 5/28/16 to 6/4/16, lacked daily wound care was done in 4 of 8 days.

5. Pt. #9 was admitted on 4/29/16 with diagnosis of Acute Osteomyelitis, Multiple sites The clinical record was reviewed on 6/8/16 at approximately 10:30 AM. The record included the pt. had a multiple wounds, including wound to left heel,right and left trochanter, right and left ischial tuberosity coccyx and left groin. The record included a physician's order dated 4/29/16 for wound care, right trochanter and left heel- cleanse with normal saline and apply dressing, left trochanter, right ischial tuberosity- cleanse with normal saline and apply leptosperum honey and dressing. The wound care order for coccyx and Right Ischial Tuberosity was dated 5/4/16 indicated cleanse with normal saline, apply dakin's solution, 1/2 strength and apply dressing. The SN wound flow sheet dated 5/5/16 to 5/19/16, lacked daily wound care was done in 7 of 16 days.


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6. The clinical record of Pt #1 was reviewed on 6/7/16 at approximately 10:30 AM. Pt #1 was admitted on 5/4/16 for wound management. The physician ordered daily dressing changes to the wound. The SN (Skilled Nurse) Wound Flowsheets dated 5/10/16 to 5/18/16 lacked documentation that wound care was conducted in 4 of 9 days.

7. The clinical record of Pt #2 was reviewed on 6/7/16 at approximately 3:30 PM. Pt #2 was admitted on 4/27/16 for wound management. The physician ordered daily dressing changes to the wound. The SN Wound Flowsheets dated 4/28/16 to 5/20/16 lacked documentation that wound care was conducted in 11 of 29 days.

8. The clinical record of Pt #3 was reviewed on 6/7/16 at approximately 2:30 PM. Pt #3 was admitted on 5/20/16 for wound management. The physician ordered daily dressing changes to the wound. The SN Wound Flowsheets dated 5/20/16 to 6/6/16 lacked documentation that wound care was conducted in 5 of 22 days.

9.The clinical record of Pt #7 was reviewed on 6/8/16 at approximately 8:30 AM. Pt #7 was admitted on 5/10/16 for wound management. The physician ordered daily dressing changes to the wound. The SN Wound Flowsheets dated 5/11/16 to 5/31/16 lacked documentation that wound care was conducted in 6 of 20 days.

10. The clinical record of Pt #8 was reviewed on 6/8/16 at approximately 9:20 AM. Pt #8 was admitted on 4/29/16 for wound management. The physician ordered daily dressing changes to the wound. The SN Wound Flowsheets dated 4/30/16 to 5/26/16 lacked documentation that wound care was conducted in 12 of 33 days.

11. The clinical record of Pt #10 was reviewed on 6/8/16 at approximately 10:30 AM. Pt #10 was admitted on 4/21/16 for wound management. The physician ordered daily dressing changes to the wound. The SN Wound Flowsheets dated 4/22/16 to 5/11/16 lacked documentation that wound care was conducted in 9 of 20 days.

12. During an interview on 6/8/16 at approximately 11:30 AM, E#1 (Director of Quality Management) and E#2 (Wound Care Nurse) verbally agreed Pt#1-10 lacked documentation the daily dressing changes were conducted as ordered.

Based on document review and interview, it was determined the LTACH (Long Term Acute Care Hospital) failed to ensure non-employed nursing staff were adequately supervised. This has the potential to affect all patients (average daily census of 24 patients) receiving cares.

Findings include:

1. The Daily Assignments and Census sheets dated 5/5/16 through 5/19/16 were reviewed on 6/7/16 at approximately 12:30 PM. The sheets noted Agency Contracted Nurse (E#5) as the 7:00 AM to 7:00 PM House Supervisor six of the fourteen days reviewed.

2. During an interview on 6/7/16 at approximately 12:30 PM, E#4 (Interim Nurse Manager) stated that due to a high census in May 2016 a lot of Agency Nurses were utilized. E#4 verbally agreed E#5 was an Agency Nurse and was functioning as the House Supervisor.